System-wide changes improve diabetes care

To improve metrics of diabetes care, 4 employed primary care practices at a health system in Texas worked to systematically improve HbA1c testing and started a “Saving Toes” campaign.

Where: 4 primary care practices in the Houston Methodist health system in Texas

The issue: Improving metrics of diabetes care


When Julia Andrieni, MD, FACP, came to Houston Methodist in 2013, the health system had only been directly employing primary care physicians for a little over a year, but the practices already had a strong drive to support quality improvement.

The practices also launched a Saving Toes campaign that treated the diabetic foot exam as a vital sign at check-in for diabetic patients
The practices also launched a “Saving Toes” campaign that treated the diabetic foot exam as a vital sign at check-in for diabetic patients.

“We were a fairly new primary care group, and we had said as part of our vision we wanted to be a patient-centered medical home, and we wanted to adhere to those standards,” said Dr. Andrieni, vice president of population health and primary care. “We wanted to build a premier primary care network with a backbone of quality.”

To accomplish that goal, 4 of Houston Methodist's employed primary care practices (Bellaire, Memorial, Pearland, and Willowbrook) began the process of applying for certification as patient-centered medical homes (PCMHs). They chose to center their required quality improvement project on diabetes care. “Since we were a new primary care network, we chose Houston Methodist's Primary Care Group practices that had sufficient EHR data for the PCMH application,” Dr. Andrieni said.

How it worked

To meet its goal, Houston Methodist collaborated with the ACP Quality Connect: Diabetes initiative and its Bridges to Excellence Diabetes Care Recognition program. All physicians in the 4 practices were encouraged to work toward Bridges to Excellence recognition. Dr. Andrieni, who served as the project's champion, invited the ACP quality improvement group to come to Houston and work with physicians and staff to provide training and CME about diagnosis and treatment of diabetes. The practices also participated in ACP's Diabetes Practice Assessment, which evaluated clinicians' and staffs' ability and willingness to improve diabetes care and helped them focus on opportunities for quality improvement.

The 4 practices worked to systematically improve HbA1c testing in their diabetic patients. Medical assistants (MAs) were trained to recognize the core diabetes quality metrics to include HbA1c below 7%, below 8%, and below 9% and overall appropriate HbA1c screening and to flag any test results that needed attention from physicians. A diabetes “huddle sheet” was developed for MAs to track the diabetes core metrics needed before the patient visit. Physicians then worked with the patients to bring their glycemic control to target levels. The practices also launched a “Saving Toes” campaign that treated the diabetic foot exam as a vital sign at check-in for diabetic patients. Performance data and feedback on diabetes tests needed at the next patient appointment were sent to the practices “to see if they were moving the needle,” Dr. Andrieni noted.


Performance measurements before and after the quality improvement project showed astonishing differences, Dr. Andrieni said.

“If you look at the screening before we did quality improvement, our [HbA1c] screening [rates] at those 4 practices are anywhere from around 19.6% to 39.1%, but then after we're up to 81.3% to 86.9%. That's amazing in terms of screening,” Dr. Andrieni said.

She noted that percentages of patients with HbA1c levels below 7%, 8%, and 9% also improved greatly as a result of the project, as did rates of diabetic foot exams, with increases ranging from 6.41% to 30.93% after implementation of the Saving Toes intervention.

“I didn't expect to see these results in a short span of time. This was a surprise even to me. We have engaged physicians and staff who are dedicated to quality,” Dr. Andrieni said.


Dr. Andrieni noted some challenges in moving from a traditional medical model to a PCMH, which she characterized as moving to a more patient-centric model of care.

“When a patient was seen in a traditional model, patient appointments would be scheduled regularly in 3 months, 6 months, or in a year,’” she said, “but in a patient-centered medical home, we utilize data from the EHR to look at those hemoglobin A1cs greater than 9 and say, ‘We have to outreach to those patients who are at greater risk and schedule them for follow-up in order to identify patient barriers to achieving our goals.’”

To help bridge these gaps, the practices used nursing care navigators trained in motivational interviewing to try to determine why patients were having problems with adherence, such as issues with medication side effects, health literacy, or lack of transportation to appointments.

“It's not so much onus just on the patient, it's an onus on the PCMH team to reach out to the patient to see why they haven't been in, how can we help them … So that was sort of a new approach and a new way of thinking. We made every effort to engage patients in their own health,” Dr. Andrieni said.

Next steps

Houston Methodist is expanding its quality improvement efforts to include hypertension, lipid management, depression screening, and smoking cessation, Dr. Andrieni said, and also had a physician CME event on evidence-based diagnosis and treatment of depression and generalized anxiety in primary care. The latter seemed like a natural next step because of the strong link between diabetes and behavioral health, she said.

“In speaking with the physicians, it was ‘OK, that's great, we're learning about diabetes and what are the appropriate tests and how do we manage this better with a system, but we need to do more work on this behavioral health issue,’” she said. She noted that the 2014 PCMH certification guidelines also emphasize the importance of behavioral health and chronic disease management.

Words of wisdom

Buy-in is critically important to quality improvement efforts, Dr. Andrieni stressed. “You want to get all your stakeholders around whatever your quality improvement issue is, and you want to make sure you have identified the right stakeholders, because it's probably a larger group than you'd originally thought,” she said. It also takes a team effort to improve quality, she stressed.

She also noted the importance of taking time out of everyone's busy schedules to pause and to recognize success. “The quality development specialists bring [practices] their certificates for obtaining Bridges to Excellence recognition. We had a celebration when 4 of our primary care practices received their PCMH recognition at the highest level,” she said. “You want to not only give them thoughtful data on a regular basis, but when there are successes, take time to celebrate them.”