Blue Care Network Best Practices
Patient follow-up and education are critical for diabetes care in Eastpointe practice
Douglas Hames, M.D., believes in strict follow-up with his diabetic patients, especially if their diabetes is not well controlled. For those patients, he schedules a follow-up visit every three months, sometimes with visits in between, he said.
Strict follow-up also means having patients keep blood sugar logs using glucometers every one to two weeks. "This helps me make judgments in between visits," explains Dr. Hames. "If you wait three months to get another A1C, then you lose time if a diabetic isn’t well-controlled. They need that extra scrutiny," Dr. Hames says.
Patient education is also part of every visit. Dr. Hames schedules 30-minute visits to provide time for conversations and patient education. "It’s one way I try to communicate the idea of getting testing done in the first place," said Dr. Hames.
Dr. Hames says he also looks for opportunities to identify diabetic patients during visits. "You can’t wait until they come in sick. I am proactive looking for diabetes. I schedule A1Cs for many patients. It's not a rule across the board, but I am liberal about doing it," he says.
Developing awareness among the office staff is important to tracking diabetic patients and ensuring that they have the recommended testing done at the right intervals. Dr. Hames says the practice uses a disease registry that alerts him when patients are due for tests. A separate system is used to identify patients who don't come in on time for testing.
The biggest challenge is when patients are overdue for testing. "That means we've failed at our attempts," said Dr. Hames.
The practice nurses use more than one method to track patients. Everyone in the office has a specific assignment. One person generates reports and the manager runs the office operations. Nurses and assistants are assigned to getting the records when labs are due. Some labs are able to enter data directly into the registry. But getting reports back from diabetic eye exams requires more follow-up because the office needs a written report for each patient. "It's a lot of manual work," Dr. Hames said.
The one flaw in the system is that the current software does not have the ability to track results easily. "So we have to go back and run reports from our registry on who is behind," said Dr. Hames. "I am actively looking to buy a module that will let me capture that data electronically."
Dr. Hames says it's the combination of office protocols and staff commitment that has led to his high diabetic screening. "I got much better data when I became serious about watching my diabetics," he said. "Managing diabetic patients is a staff effort. We enjoy getting better data and I believe we will continue to improve."