Creating a Healthier Population By Achieving the Triple Aim in a Community-Based Diabetes Clinic

After managing a growing community’s underserved diabetes population for 6 years, a collaborative BSN student nurse and faculty nurse practitioner provider partnership decided to begin to implement the Institute of Healthcare Improvements’ Triple Aim as a progressive goal to further improve a population’s outcomes. The collaborative partnership began to focus on the Triple Aim’s three goals for optimizing a health system’s performance. The three goals of the Triple Aim are improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.  Previously, the major goal of the collaborative partnership was to improve the health of the population as evidenced by improvement in HbA1c levels. The goal was to improve and maintain optimum HBA1c values and prevent diabetes complications for the population. The collaborative partnership added the triple aim goals of improving the experience of care and reducing per capita cost for ongoing care of this underserved diabetes population. The collaborative decided to use the IHI suggested measures for the triple aim outcomes. The patient experience is measured using a survey to assess the patient’s perception of their experience while receiving primary care and disease management at the diabetes clinic located at a community health center. The per capita cost is measured by documenting hospital and ED utilization rate. The health of the diabetes population is measured by reporting HBA1C and complications of diabetes.  The purpose of this presentation is to describe a fully implemented school of nursing diabetes clinic that contributes to creating a healthier community by achieving the Triple Aim outcomes.     

Literature to support this research based practice study centers on several references. The Institute of Healthcare Improvement recommendations and goals serve as a guide for developing healthier communities by achieving the Triple Aim goals for patient populations. A significant research based manuscript that supports the use of a collaborative nursing faculty practice through a nurse managed health center is the manuscript published in 2015 by Pilon, Ketel, Davidson, and Gentry in The Journal of Professional Nursing. The book, Future of Nursing, supports this diabetes population initiative in the fact that it calls for more access to high-quality, patient-centered, affordable care. Embracing Change (2015) by Orr and Davenport, reviews the research based evidence for transforming nursing practice. A BSN Action Guide for Responding to the 2011 Institute of Medicine Recommendation in the NLN book, Building the Future of Nursing (2014) by Orr and Ciampini gives examples how BSN nursing programs can take actions to meet the first two IOM recommendations related to improving the scope of practice and leading collaborative improvement efforts; both of these recommendations are advanced by this diabetes population initiative. The research by Haelle (2015) documented fewer hospitalizations for people with diabetes by nurse practitioners. Bender (2014) found that treatment adherence and disease self-management improve with patient access and provider training.              

Care of the underserved population includes primary care and disease management which takes place at a community health center diabetes clinic staffed by faculty Family Nurse Practitioners (FNPs) while integrating BSN Community Health course students into the collaborative partnership. With a scarcity of community health clinical preceptor cites, the collaborative was seen as adding a clinical site for BSN Community Health students and giving them an opportunity to practice as student nurse providing community health interventions in support of the FNPs treatment plans for the patients in the managed population. The FNP communicates with the assigned students the treatment plan and behavior changes that are needed for the patients in follow-up to the primary care visit. The community health center has limited access to secondary referral providers or an interdisciplinary team of providers, which makes it essential that primary care and support care givers prevent complications from diabetes. The collaborative partnership program provides care that was previously not available to this uninsured population.  The salary payment of the faculty FNPs is covered by a county community health foundation grant that has been renewed 4 times and has been in existence for 6 years. The faculty FNPs participate in the diabetes clinic once a week. The faculty nurse practitioners’ practice at the diabetes clinic is in addition to their fulltime teaching responsibilities. This primary care practice time meets requirements for continued certification as a FNP. The funds for this grant originate from the previous sale of a community hospital. One of the primary goals of the county health foundation was to use the resulting funds to improve access to care in the community and to create a healthier community. The diabetes clinic has significantly contributed to meeting this goal of the health foundation by progressively increasing the number of patients seen and followed at the diabetes clinic over the past 6 years. Grant proposals and re-applications for funding have been written by the School of Nursing’s endowed Chair of Excellence. Re-applications for the foundation grants required demonstration of ongoing improvement in patient health status as demonstrated by improving and maintenance of controlled HbA1c values and increasing numbers of patients having access to care at the clinic. The number of underserved patients being managed in the diabetes clinic is presently 1140 participants.  

Education of the community health student nurse team members previously focused solely on the evidence-based care interventions for patients with pre-diabetes and diabetes.  In addition, the students were taught the importance of preventing diabetes for the at-risk pre-diabetes population and preventing complications in the diabetes population. In order to prepare the student for a more encompassing broader focus of health care as described in the Triple Aim, the BSN community health students were educated on the global focus of the IHI Triple Aim Initiative. The students were then taught to intervene to not only achieve the population health outcomes, but also how to intervene to achieve improvement in the patient experience and reduce the per capita cost outcomes.

Based upon the IHI Triple Aim the diabetes clinic initiative has three specific process based outcomes that center on answering the three research questions which are: Can the care providers provide primary care, disease management and care coordination that promote participant behavior change that results in 1) improved or maintained HbA1c values; 2) positive reports from participants of the patient experience at the diabetes clinic; and 3) prevention of the need for participants to seek emergency department and hospital admissions for diabetes related complications. The diabetes clinic is available weekly for 8 hours at a community health center that serves underserved and underinsured patients. The diabetes clinic is managed by the school of nursing faculty. Primary care and education in self-care is provided by the school of nursing FNP faculty and BSN community health nursing students. Outcomes for a patient population of 150 participants that entered the program over the last 12 months, who have had at least 2 visits, include a baseline aggregate HbA1c of 7.89 %and a second aggregate HbA1c collected on the second follow-up was 7.77%. Outliers (sixteen participants) who had significantly out of control HbA1c values had an average improvement of decreasing values of an aggregate 4.33% from first visit to second visit. These were patients that had HbA1c values of 17.1%, 15.6%, 14.2%, 13.8%, 11.8% and down to 9.3% on their first visit and needed significant improvement in blood sugar control to prevent complications.

Measurement of the participants’ patient experience and emergency visits are measured through a patient survey that has five questions. Three patient experience questions focus on provider interest in the patient as a person (95% positive); patient’s confidence in getting the medical care they need (91.6% positive); and relationship with the primary care provider motivates to adhere to their treatment plan (100% positive). The two emergency (ED) department survey questions came back much less positive. Two survey questions asked if the patient has received care in the emergency department in the last 6 months (62.4% reported that they had accessed the ED) and if they had been back to the ED since having access to care for treatment of their chronic illness (54% reported that they had accessed the ED). The measurement of ED visits represents much opportunity for improvement in more effectively helping the patient manage their diabetes and hypertension at the diabetes clinic and discuss options with the patients for focusing on early prevention rather than emergency intervention. With the ED survey questions not addressing cause of admission it might also be of benefit to question if the cause for seeking ED access was related to diabetes or hypertension.