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Feasibility and Effectiveness of System Redesign for Diabetes Care Management in Rural Areas

The Eastern North Carolina Experience

From the University Health Systems of Eastern Carolina, Greenville, North Carolina (Mr Bray, Ms Roupe, Ms Young, and Ms Harrell); Brody School of Medicine at East Carolina University, Greenville, North Carolina (Dr Cummings and Dr Whetstone); and the University of North Carolina at Chapel Hill, School of Pharmacy (Dr Cummings).

Correspondence to Paul Bray, MA, University Health Systems–Bertie Memorial Hospital, 2100 Stantonsburg Road, Greenville, NC 27834 (pbray{at}pcmh.com).

Purpose

Redesigning the system of care for the management of patients with type 2 diabetes mellitus has not been well studied in rural communities with a significant minority population and limited health care resources. This study assesses the feasibility and potential for cost-effectiveness of restructuring care in rural fee-for-service practices for predominantly minority patients with diabetes mellitus.

Methods

This was a feasibility study of implementing case management, group visits, and electronic registry in 5 solo or small group primary care practices in rural North Carolina. The subjects were 314 patients with type 2 diabetes mellitus (mean age = 61 years; 72% African American; 54% female). An advanced practice nurse visited each practice weekly for 12 months, provided intensive diabetes case management, and facilitated a 4-session group visit educational program. An electronic diabetes registry and visit reminder systems were implemented.

Results

There was an improvement in the percentage of patients achieving diabetes management goals and an improvement in productivity and billable encounters. The per-centage of patients with a documented self-management goal increased from 0% to 42%, a currently documented lipid panel from 55% to 76%, currently documented aspirin use from 25% to 37%, and currently documented foot examination from 12% to 54%. The average daily encounter rate improved from 20.17 to 31.55 on intervention days.

Conclusions

A redesigned care delivery system that uses case management with structured group visits and an electronic registry can be successfully incorporated into rural primary care practices and appears to significantly improve both care processes and practice productivity.

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