Monica Manga, MD, FACP, an internal medicine physician at Visalia Medical Clinic, recently served as medical director of a pilot program for high-risk diabetes care that resulted in improved patient health and cost savings.
The program, in collaboration with the Kaweah Delta Chronic Disease Management Center, was recently highlighted in a series called "Quality Improvement Success Stories," published by the American Diabetes Association.
Tulare County has the highest prevalence of type 2 diabetes in the state at 13.2%, which is nearly twice the statewide average of 6.9%. The pilot program focused on residents with type 2 diabetes who met certain criteria, such as chronically high blood sugar, high usage of the emergency room and hospital, high pharmacy costs, gaps in care, and self-identified poor health.
Patients benefitted from access to a multi-disciplinary team, which included doctors, nurse practitioners, clinical pharmacists, nurses, dietitians, and certified diabetes educators. Each patient was assigned a community health worker who made home visits and consistently checked in with patients regarding their health care plan, medication list, blood glucose logs, lab orders and medical appointments.
The care team met every two weeks to review each patient's progress and identify areas of need.
The result was a 100 percent achievement in blood sugar control goals within the program's 21 graduates, who also reported a higher perception of their own health. Medical expenses incurred by the patients dropped by $85,570, among other benefits.
"The program proves the value of a multi-disciplinary, patient-centered approach to helping type 2 diabetes patients manage their health," said Dr. Manga, who continues to serve as the program's medical director.
"Social and behavioral issues can prevent patients from properly managing their health, but this program helps remove those barriers and provide the support they need to be successful. We have found that graduates are informed, motivated and ready to take actions toward their own care."
The program continues through the Chronic Disease Management Center for patients who meet the criteria. For information, call the center at (559) 624-4080.