Lead/Presenter: Kathie Hermayer, COIN - Charleston
All Authors: Hermayer KL (Ralph H. Johnson VAMC) Fernandes JK (Ralph H. Johnson VAMC) Hunt KJ (Ralph H. Johnson VAMC) Dismuke CL (Ralph H. Johnson VAMC) Pope C (Ralph H. Johnson VAMC) Oliver L (Ralph H. Johnson VAMC) Yeager D (Ralph H. Johnson VAMC) Axon RN (Ralph H. Johnson VAMC)
The structural, economic, and cultural differences between rural and urban health care delivery and minority Veterans require a more coordinated and proactive approach to providing care. This quality improvement project conducted in collaboration with the operations partner of the Office of Health Equity aimed to improve the health and well-being of Veterans with diabetes through a coordinated approach to care and services available to them in the VA system.
A1C greater than 9.0% was compared before and after an intervention including a care coordination nurse. There are nearly one in four Veterans diagnosed with diabetes, and 21.4% of Veterans with diabetes live in rural areas. Veterans with poorly controlled diabetes ( > 9%) at the Ralph H. Johnson VAMC and surrounding Community Based Outpatient Clinics were identified. A care coordination nurse contacted Veterans to discuss support available at the VA. This approach included medication support through Patient Aligned Care Team pharmacists, scheduling primary care visits or HbA1c orders, referrals to Telehealth, and e-consults to the diabetes advanced practice registered nurse, diabetes educator and dietitian.
After 9 months of implementation, over 1,000 Veterans with diabetes were contacted and connected with VA services. 14% were rural Veterans, mean age was 60, and 45% were African American. The percentage of Veterans with poorly controlled diabetes decreased from 81% to 64%. Performance measures for diabetes care also improved from 26% poorly controlled to 15% poorly controlled, bringing our facility scores below both VISN7 and National performance measure standards for uncontrolled diabetes. Among non-Hispanic Black Veterans with diabetes, the proportion of patients with HbA1c levels > 9%, decreased from 20% in early 2015 to 17% at the end of 2016. For Hispanic patients, this proportion decreased from 15.1% to 10% during the same period.
A proactive and coordinated approach to improving access to VA services for Veterans with diabetes was effective at improving HbA1c for those with poorly controlled diabetes.
This practice was successful at decreasing disparities in diabetes care, because it was thoughtfully planned, had strong leadership and VA support, included a multidisciplinary team and worked to be Veteran-centered.