WASHINGTON, DC—Diabetes is, in many ways, the prototypical chronic disease. It is slow moving, progressive, complex, and it impacts patients’ lives in ways that cannot be quantified on a medical chart. Physicians at the Department of Veterans Affairs have learned a lot about treating diabetes over the last several decades, and during that time, certain concepts have emerged: shared decision-making processes, patient-guided treatment, and population management. Now, as VA undertakes a system-wide effort to evaluate and redesign its primary care delivery system, those concepts are helping to guide a process that will help move VA care, including diabetic care, into the 21^st century.

From Episodic to Continuous Care

Over the next several years, VA will be making an effort to move towards a patient-centered model of care. This model looks at health care as a process extending beyond a series of visits to practitioners. “We need to think about health care in a continuous fashion,” explained Dr Mike Hein. Doctor Hein, the medical director for primary care in VISN 23, has been detailed to VA’s Primary Care Program Office. He is assisting in the nationwide deployment of this new delivery model. “We need a care delivery model that recognizes high quality care happens not just at face-to-face care, but at non-face-to-face care. High quality care can happen whether or not the patient sees the physician.”

This model requires a team of qualified individuals surrounding the patient, including clinical pharmacists and nurses with special training in disease management, who can assist in delivering care. It also requires investments in technology, especially telehealth technology, which can help patients manage their disease and keep in touch with providers remotely. Additionally, patients would have a far stronger voice in that care, discussing with providers what would be the best care regimen for them. In short, it is a model that recognizes many VA patients are being treated for chronic conditions that evolve and progress when they are away from VA facilities. Those patients are frequently in charge of monitoring the course of their disease and the effect their treatment regimen is having.

“The usual care is that care doesn’t happen until the patient comes in to be seen at the clinic by the provider,” Dr Hein explained. “And then decisions are made and the patient goes home based on those decisions and they may not be seen for 6 or 12 months depending on the provider and status of the patient.” That delivery model has evolved and reigned over the last 100 years. And the VAsystem has managed to achieve a high level of care using that model, Dr Hein noted. But for patients suffering from chronic diseases, including diabetes, this old model can only be so effective.

Evaluating Diabetes Care

Before being tasked to the Primary Care Program Office, Dr Hein was part of a primary care leadership program that started in May 2008. One of the results of that program is a nationwide effort by VA to evaluate chronic disease management within primary care, especially diabetic care. The goal is to evaluate best practices in diabetic care throughout VA and make recommendations to the Primary Care Program Office on how VA can better deliver diabetic care. Those recommendations will likely be rolled into the deployment of this new care model over the next several years.

VA collected a group of primary care leaders from across the country, which looked at the available medical literature and determined what areas of diabetic care should be examined. Next, VA began a quantitative assessment using VA data sources to identify facilities that are positive deviators from the mean, as well as those that are underperforming. The next process—the one currently underway—is a qualitative assessment of those sites, involving a telephone interview with a researcher. “We want to see if we can find out more information about what’s going on at these facilities in regards to diabetic care and matching up the quantitative assessment of the data with the qualitative assessment of the interviews,” Dr Hein explained. “By the time we’re done, we’ll probably have interviewed close to 30 or 40 sites across the country.”

The next step will be to identify a handful of those sites and visit them face-to-face to get a better understanding of what’s going on there in terms of diabetic care. Doctor Hein expects to see that process completed by May, after which a report will be issued. “I think we’re going to find some consistent and valuable information that will help guide policy in the future for chronic disease management and diabetic care in particular,” he said.

One Size Does Not Fit All

One area that VA will need to address as it moves to a patient-centered delivery model is how success in diabetic care is measured. “Most health care systems are using sort of a one-size-fits-all benchmark that determines care. In the last couple of years, there has been significant literature published around diabetic care that suggests we need a more thoughtful approach to how we determine what high-quality diabetic care is,” Dr Hein noted. “Also, there’s quite a bit of variability across the country. We want to understand what that variation means and try to flatten out that distribution curve so care is more standardized. And look at those components of care that can be improved. We think we’re pretty good now, but there’s a sense that we could be even better, particularly if we’re able to understand the variation that exists.”

When it comes to aggregate numbers, the question becomes whether the data facilitates positive action, or if it is an abstract number that has little bearing on reality. Doctor Leonard Pogach, VA’s diabetes chief, who is co-chairing the diabetes redesign effort, likes to use the analogy of grades in education. “If you looked at a high school and you gave it an average score for math, what does that mean? What does that mean compared to knowing the scores for 9^th, 10^th, 11^th and 12^th grade? And then, what if you knew the classes within each of those grades? And then you could get down to the individual teacher. It’s a paradigm for the health care system.” Similarly, “you can say there are 24 million people with diabetes, but they aren’t all the same,” Dr Pogach declared. “Yes, you have to deal with veterans one at a time, but I think the question is: What would be the goal for a younger, healthier adult? Someone who’s 50 with no other problems might be a lot different than someone who is 50 who has significant liver problems, or someone who is 50 that lives in a group home with mental health problems and can’t follow a regimen.”

Any move towards a patient-centered model must also take into account the idea of population health, Dr Pogach explained. When identifying best practices, VA cannot assume that the benefits and risks with care regimens will be the same for every patient population. And the patients within that population might have a different understanding of what quality of care is than is generally understood by the health care system. “The way that we manage chronic disease is oftentimes very health-system-centric,” Dr Hein admitted. “We’ll use measures like glucose control, like hemoglobin A1C less than 9%. But the patient doesn’t have that kind of reference point. They’re measure of quality of care is: Could I get in and see the provider and did they listen to me? Am I going to live long enough and live well to see my grandchild graduate from high school? Am I going to be able to drive my truck for a living? We need to be sensitive to those preferences and how patients determine quality of care when we measure our success as a health care system.”

Data Management

Identifying patient populations requires a serious commitment in technology and data resources. If physicians want to identify and locate all 50-year-old patients with diabetes and see what particular medications they are on, that will require registries and data management. Plus, that information cannot be outdated if VA wants to provide the best care at the right time. “We need to improve technology at the time of the visit,” Dr Pogach said. In other words, VA needs to have better access to real-time information tracking a patient’s progress and condition. There are currently efforts to improve communication with patients through MyHealtheVet—the online system that allows patients to have access to their medical records—but those efforts have not made it out into the field yet.

The end-goal is to have real-time evaluation of patients’conditions, as well as a better understanding of what patient populations are most at-risk for diabetes-related conditions. “What we’re talking about in the future is identifying specific populations and identifying those in a proactive way using things like a data registry or a patient registry,” Dr Hein explained. “That would allow front-line providers to survey the patients that they’re responsible for using this data registry tool and identify these high-risk patients. Then care can actually be taken to the patient instead of waiting for the patient to come and see the provider.” Physicians would be able to identify patients who are not adequately managing their condition, speak to them, and work with them around their schedule, in a patient-centered way, to help them improve their care.

Shared Decision Making

One aspect of this patient-centered model of care that VA is already implementing, but which could be improved, is shared decision making, Dr Pogach noted. “In the VA, we believe evidence starts as the basis of clinical policy. And clinical policy informs everything that we do.”

Since patients suffering from diabetes are responsible for much of their own care, VA believes in being open about the strength of that evidence. “A-level evidence would be: We think you should do this unless there’s a specific reason why you don’t want to or can’t,” Dr Pogach explained. “B-level would be: There’s evidence to support this, but we don’t necessarily know if this will make a difference in your life.”

One example would be the conventional wisdom that people take aspirin for prevention of cardiovascular disease, which diabetics are at a higher risk for. Evidence has been inconsistent with the benefit of this treatment. “This is an area where you need to talk to your patient. VA and DoD have always been very explicit about the level of evidence and incorporating shared decision-making,” Dr Pogach said.

Patient and Physician Education

If patients are to become more involved in determining the course of their care, they need to be better informed about their disease and the treatments for it. In addition, physicians need to be better informed about their patients’ lives outside of the exam room.

A member of VA’s Insulin Safety Subcommittee, Dr Pogach believes that helping patients improve their understanding of insulin and what it does is one area that VA should focus on. While most patients with type 2 diabetes do not start on insulin, those who suffer from the disease long enough will eventually need it to maintain adequate control. Insulin therapy has a relatively high risk of complications, mainly hypoglycemia. Some studies from 2007 suggest that it is the most common cause of adverse drug reactions in the elderly. “One of our goals should be that we can really help veterans that are starting insulin, or those that are on insulin and need assistance, to better manage themselves,” Dr Pogach explained.

That might, for some people, involve increased health literacy. Some patients require a better understanding of how nutrition affects their condition, including caloric intake and how to read the information on the back of food products.

Physicians also need to recognize that some of the barriers to treatment patients have exist within their communities. “Many communities don’t have healthy foods…and the patient may have some personal issues or social support issues as well,” Dr Pogach explained. “When we talk about patient-centered care, I think we’re talking about not only what we can do within our system, but how we can understand what the veterans’ issues might be outside our system and, to the extent possible, how we can help them address these issues and point them in the right direction to find what might be available in their communities.”

Putting the Patient in the Center

As far as VA’s transformation to a patient-centered model of care, Dr Hein believes that the system is already 70% there. But the last 30% is a big shift, one that includes a serious culture change for everyone involved in the delivery of care. The previous model puts the physician at the center of everything. The patient arrives at a clinic, sees the physician, who in turn tells the patient what to do. There is a support team of nurses, pharmacists, and other employees to help make sure the physician’s orders are carried out. This new model puts the patient at the center of everything and surrounds them with a team of trained providers acting in concert.

“This transition will be a significant culture change. It will involve an understanding of the roles and responsibilities by everybody on the care team, even the clerks and the health techs who assist in deploying care,” Dr Hein explained. “It’s a huge transformation in how we understand care is delivered. This represents a big transition for patients as well. They will have to be trained to consider themselves an active partner in deciding how their care will proceed. Chronic diseases like diabetes require significant lifestyle changes for patients, which can only be carried out through the patients’ own efforts. They have to be educated on using technology in a continuous fashion, supporting their decisions, and using their preferences as a guide in supporting how decisions are made,” Dr Hein explained.

The concept of a patient-centered model might not be possible without the lessons learned from treating patients with chronic diseases like diabetes. “We’re trying to take that knowledge, especially around patient preferences and self-management tools and skills, and develop that same kind of approach to things like congestive heart failure or hypertension or hyperlipidemia and other chronic diseases,” Dr Hein explained. “To bring the patient onto the team, listen carefully to what their preferences are, work with them in a shared decision model of care, and provide the kinds of tools and support the patients and their families need to have in order for their disease to be well-managed.”

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