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ID PLUS Care program developed to help at-risk type 2 diabetes patients within UMass Memorial receive the care they need

Date Posted: Tuesday, February 18, 2020

41. Daniel Amante and Adarsha Bajracharya

Key to a long and healthy life for people living with type 2 diabetes is maintaining blood glucose within a specified target range. Proper diabetes self-management results in healthy blood sugar levels, thus reducing the risk of developing serious complications from poorly-controlled diabetes. Testing blood sugar on a regular basis is extremely important. This includes both regular checks throughout the day using a meter and A1c tests 3-4 times a year.  

Many people receive their diabetes care from a primary care provider (PCP). As patients with diabetes often experience multiple chronic health problems and have limited time with their PCPs, receiving comprehensive, guideline-recommended diabetes care can be challenging. A new initiative within the UMass Diabetes Center of Excellence (DCOE) has begun to track patients at-risk for negative outcomes due to gaps in care, proactively engage them to identify their difficulties and “nudge” them towards available services and resources to get them back on track.  

The project is a collaboration between UMass Memorial Health Care and UMass Chan Medical School, led by Daniel J. Amante PhD, MPH and Adarsha Bajracharya, MD. Alongside clinical partners from the UMass Memorial Office of Clinical Integration, they’ve developed a computer program within the Electronic Health Record (EHR) system to identify people living with type 2 diabetes who have not recently visited their PCP, have an A1c greater than 8%, are due for an annual eye, foot or urine test, or have not had an A1c test within the past six months.  

“Our ID PLUS Care program monitors the EHR data of UMass Memorial patients with type 2 diabetes in order to help those at increased risk for negative outcomes,” said Dr. Amante. “We contact them personally to better understand the reasons behind their gaps in care so we can guide them towards available resources.”

Specially trained outreach specialists are learning about the challenges and frustrations that are getting in the way of people properly managing their diabetes. “Many find it helpful and are thankful to have us contact them,” said Anna Lu, one of the clinical research assistants making the phone calls. “They appreciate our help scheduling the many appointments that people living with diabetes need. Especially those who don’t have a well-established relationship with their PCP.”     

In addition to compiling an abundance of underutilized local resources to provide those in need, the outreach specialists also let people know that the UMass Diabetes Center of Excellence offers certified diabetes educators and nutritionists to help with everything from getting started with healthy eating and physical activity to blood sugar monitoring, problem-solving, healthy coping and reducing risk of complications.  

“Our approach has shown positive results as more patients are now getting their recommended tests and seeing their care providers,” said Dr Bajracharya. “By helping these people get their diabetes under control before they develop complications, we can prevent or reduce the risk of complications, reduce cost, and improve their quality of life.”

The program has uncovered a wide range of obstacles that have kept patients from receiving necessary care. “Everything from transportation issues, to not having the time to reschedule a missed appointment, to the cost of insulin and other medications,” added Dr. Amante.

While the goal of this program is to improve diabetes care management for at-risk patients, the strategies and impact can also be applied to help with other chronic disease management in the future.

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