By Steve Spotswood

Annie Bowen, RN

Annie Bowen, RN

ZANESVILLE, OHIO — The Zanesville Community Based Outpatient Clinic is pretty typical when it comes to VA community-based outpatient clinics (CBOCs). Situated in a rural stretch of eastern Ohio, it’s where several thousand veterans receive their regular VA care. It has three patient-aligned care teams (PACT), with each team overseeing the care of about 1,100 veterans.

Like all VA facilities, its largest concerns center on managing chronic disease in an aging patient population. Diabetes is near the top of that list, but, until recently, the Zanesville CBOC had been faltering in its delivery of diabetes care.

“In the VA, we have reports and we have benchmarks we have to meet,” explained Annie Bowen, RN, the nurse manager at the Zanesville CBOC. “We weren’t meeting the benchmarks. We were pretty outside the benchmarks. We have tools to help us stay within the numbers. Some months we were in. Some we were out.”

That was in December 2013, when Bowen first arrived at Zanesville. She had spent the last two years at a home-health agency but had wanted to be a nurse at VA ever since reading an expose on the then-Walter Reed Army Medical Center during her time in nursing school. She had also spent time working for Nationwide Children’s Hospital in Columbus.

“When I was at Nationwide Children’s, I taught diabetes education to families of newly diagnosed children,” she said. So when she arrived in Zanesville and saw the numbers, she began examining how the CBOC could do better.

The first step was simple: Make sure as much health data was being collected from patients as possible.

About one-third of the patients at Zanesville has diabetes and appears as such on the VA’s chronic-disease registry. Many, however, had not been tested through VA in years. These veterans were seeing a private primary care physician but would get medications through VA.

“I would say maybe 10% of our population [of about 3,500 veterans] were getting labs done in their community. And it wasn’t registering with the VA at all,” Bowen explained. “They’d tell us verbally what their hemoglobin A1C (HbA1c) levels were, but we could not trend it.”

Only if their labs were done at VA would the data make it to the national registry. And, because the PACT system is designed to provide personalized care to veterans, without regularly updated HbA1c data, the facility could not track how the patient was progressing or know when or how to adjust care.

So, Zanesville sent out a letter to every diabetic veteran whose levels were high or who had not had their labs done at VA recently. Veterans started coming to the CBOC for their labs, and copies were sent to their community physicians.

Once armed with current data, the PACTs were able to tailor patient care accordingly. Each team developed their own strategy, but each made use of all the CBOC’s resources, which include an on-site anticoagulation and diabetes clinic run by the clinic’s pharmacist.

“We try to individualize care for what’s going to work best for each patient. Then we just encourage them to keep doing it,” Bowen said. “If they like it, it will work for them.”

Whatever combination of methods the patient receives, the goal is the same— fewer disease-related complications and a better quality of life.

The nationwide goal for VA is to keep the number of patients with high HbA1c levels to 21% or lower. In April 2014, before the clinic started focusing on diabetes, its three PACTs were at 20%, 19.6% and 23%. By August 2014, all were well under the benchmark: 18.3%, 13.7% and 18.4%. The clinic’s numbers have stayed below the national average ever since.

“We’re still getting data, but the consensus of our PACT teams is that diabetes-specific hospitalizations have decreased as well,” Bowen said.

Fresh off its success targeting diabetes, Zanesville is looking at how it can use this same kind of concentrated focus to address other chronic diseases. Starting this spring, each PACT will choose a chronic disease, such as hypertension, COPD, cardiovascular disease or one of the other conditions plaguing the veteran population. They will each develop a plan to help re-educate patients on their disease and work on ways to lower disease-related complications and improve quality of life.

While Bowen might have started the ball rolling, she takes little credit for the success. “It was the PACT teams working together with the patients,” she said. “It’s truly their success, not mine. They made this work. They helped devise it. They implemented it. And they’ve stayed true to this model.”