Use shared services to improve diabetes counseling

Diabetes is among the most common chronic diseases, affecting upward of 30.3 million in the United States as of 2015, according to the American Diabetes Association.

The scope of the disease has a significant impact on physician practices. According to a 2016 report in Primary Care Diabetes, showed that 48 percent of all patients with diabetes (and no other chronic condition) were made to primary care physicians.

Shared diabetes services may be essential to successfully treating patients with this disease without overburdening physicians.
Dhruv Khullar, MD, MPP, a physician at New York-Presbyterian Hospital and an assistant professor in the department of healthcare policy and research at Cornell University in New York, says that incorporating shared services such as diabetes care and behavioral health within practices is increasing.

He says there is “A growing body of evidence that suggests either co-locating these types of services within a practice, or having very easy seamless access to them can really help improve patient outcomes.”

Share to survive

Khullar says that integrating services is one way smaller physician practices may be able to survive in the face of healthcare reforms that put greater burdens on them.

“There’s not just one way to share services such as hiring a diabetes educator,” Khullar says. He recommends physicians think broadly-ranging from looking for opportunities to obtain some of these services through hospital affiliations, to partner with other small physician practices that might have such a person on staff, or to collectively share the costs of such an ­educator.

There might even be ways to get these services through payers, Khullar says. “Some commercial payers might pay for or pay partially for these types of services, particularly [under] capitated agreements.” He recommends that physicians evaluate the needs of their practice to discover the best possible strategy for shared services.

Jason C. Baker, MD, assistant professor of clinical medicine and attending endocrinologist at Weill Cornell Medicine in New York, says that integration of care has always been very important in diabetes treatment.

He outlines an ideal model in which a physician is in charge of medications and orders labs and follows up on them. Then, a certified diabetes educator and/or nutritionist delves into the day-to-day issues about how a patient can keep his or her health at an optimal level.

Integrated care is easiest when physicians and diabetes counselors are in the same location, Baker says. This allows for ease of sharing charts, notes, and communication, but in his own practice, he prefers a referral-based system. “I like to be able to pair personalities together, different nutritionists and educators to different patients,” Baker says.

He acknowledges that a downside of this approach is that it makes communication more complicated. “Unless you’re at a very large comprehensive diabetes center, you have various written reports being shared, faxed, emailed, and scanned into the EHRs and it can get a bit messy,” he says.

Baker says the benefit of an in-house diabetes educator is that the provider comes to the physician’s office and they can enters notes directly into patient charts, which alleviates communication issues, and reduces the problem of chasing each other down by phone.

The potential downside is that having an in-house educator locks patients in with that person. In that regard, he says, a physician practice will have to decide what is more important to them-being able to offer patients a variety of practitioners or having seamless communication in-house.

Another benefit of in-house integration with diabetes services is that it makes it easier for the patient to obtain better care. “Patients tend to not show up for appointments and get the care that they need if there are barriers to that care,” Baker says, such as having to travel to more than one location, or scheduling appointments on separate days. “So anything one can do to make it easier for patients will ultimately help their care.”

Additionally, he says, it can make things easier for the provider because, aside from overseeing the big picture of the patient’s care, the physician can best spend their energy on coordinating care from a big-picture perspective, and can communicate with the patient to let them know he or she will be speaking further with an educator or specialist.

However, if a physician is having difficulty determining which aspects of diabetes care to offload to a third party, Baker recommends that physicians delegate tasks such as teaching patients how to use an insulin pump or glucose meter, and nutritional counseling.
Certain mental health-related disorders such as binge eating and anorexia, which Baker says are common in diabetes, will probably need to be referred to a behavioral health professional.

“It’s not going to be possible for the physician, who many times has just twenty minutes, to do what they need to do and make treatment decisions,” Baker says.

Boost revenue

Another benefit of shared services, particularly if a physician hires additional staff, is that it could bring extra income to a practice by increasing the number of patients that can be seen.

However, he cautions that financial gain should not be the only driver of such a program. Essentially, its important for physicians to strike the right balance between productivity and quality. “I think it tends to dilute out the care when there’s a really high volume of people coming through an office,” Baker says.

Evaluating when and how to hire additional staff is a decision each practice has to make individually, says Khullar. “For some, it may make sense to hire someone full time. For others, it might be better to share one clinician across several practices.”

He says some services may be available through different mechanisms. “In some cases, insurers might help cover the cost, and in others, a local health system might. It’s also important to take into account any downstream savings or health improvements that might result when calculating the upfront cost of hiring an additional care team member.”

Regardless of how a practice goes about it, Baker says sharing services is a key part of diabetes patient care. “I think that somebody who tries to do everything on their own is not going to be successful with the majority of [diabetes] patients. You have to have a group to work with you.”

Editor’s note: The intricacies of running a medical practice and meeting myriad patient needs have increased to say the least. But there’s one solution for both issues: shared services. This occasional series will look at possibilities that physicians likely aren’t benefitting from and how they can use shared services to improve the care their patients receive.