Harris Health’s Team Approach Helps Patients Regain Control of Diabetes

Before diabetes takes or disables a life, Harris Health System wants to step in. Through an ambitious program that places patients with uncontrolled diabetes with a team of medical experts and support staff, the aim is to change the course of the disease in dramatic fashion.

As one of the leading causes of death in the United States, diabetes killed nearly 80,000 people in 2015 and was the underlying cause of death in another 250,000 deaths, according to the American Diabetes Association. The disease cost $245 billion in the U.S. alone.

Harris Health treats nearly 36,000 patients with diabetes and roughly one-third (12,000) of them have levels categorized as uncontrolled (meaning hemoglobin A1c levels—a three-month measure of a patient’s sugar levels—are above nine percent). Simply put—patients with high levels are prone to severe nerve damage, kidney failure, loss of vision, as well as life-threatening conditions like stroke and heart disease.

Harris Health serves a high rate of diagnosed patients with diabetes: 59.6 percent Hispanic compared to 12.1 percent nationally; 24.9 percent African American compared to 12.7 percent nationally; and 8.3 percent white compared to 7.4 percent nationally. A significant portion of Harris Health patients have a body mass index classification of obese (BMI greater than 30)—a high risk factor for diabetes and an indicator of poor disease management among those diagnosed.

In just two years, Harris Health’s Diabetes Multidisciplinary Program has shown great promise and has organizer, Christy Chukwu, senior operations manager, Population Health and Disease Management, Ambulatory Care Services, excited about the quality-of-life improvements she’s seen in patients.

The program connects patients with a primary care physician, a nurse, a dietitian, a certified diabetes educator, a clinical case manager and a clinical pharmacist. Each team member plays a vital role in helping patients understand the gravity of their situation and how simple lifestyle modifications—in foods, exercise and adherence to medications—can make huge improvements.

“Healthcare is a team effort, and the most important person on the team is the patient,” Chukwu says. “A key aspect of the program is our effort to strive for effective treatment by educating and engaging the patients as true partners in the management of their chronic disease.”

The program has seen an average drop in A1c levels of nearly two percent. Some patients have seen even greater success in the program now available across 14 Harris Health locations in Harris County.

To support the program and motivate participants—patients and team members--Chukwu developed a “Wall of Wellness” display at each location to promote patients who successfully manage their diabetes and the healthcare team members who helped them.

“We had two gentlemen at El Franco Lee Health Center who each dropped 7 percent on their A1c levels,” she says. “That was incredible and shows others what is possible when you keep your appointments and utilize the diabetes care team. They lost weight, exercised more and felt better about themselves. We want this positive reinforcement to show others that they too can succeed.”

Chukwu says everyone on the patient’s team supports and promotes the benefit of patients working with various members of the multi-disciplinary team. At each interaction, members provide education about their colleagues and how each can assist patients control diabetes. 

“If a patient sees a diabetes patient educator and the educator sees that he or she has questions about food, the educator will refer the patient to a dietitian,” she says. “We want to make the visit as beneficial to the patient as possible.”

Harris Health’s diabetes success is directly linked to the system’s achievement of the Physician Practice Connections-Patient-Centered Medical Home designation by the National Committee for Quality Assurance (NCQA). The prestigious recognition signifies the system’s primary care centers and clinics use evidence-based guidelines to standardize the management of chronic diseases.



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