Improving Diabetes Management Through Teamwork

Diabetes is a complex disease that, although marked by high blood glucose levels, affects the entire body. Left unmanaged, diabetes can lead to serious complications, including heart disease, stroke, hypertension, blindness, kidney disease, diseases of the nervous system, amputations and premature death.

An important part of managing diabetes is screening for diabetic kidney disease, or nephropathy. As with most diseases, early diagnosis is important to outcomes. Therefore, early detection is important for creating a treatment plan and improving outcomes.

The easiest way to meet the nephropathy screening guidelines is by collecting a urine sample annually from each patient with diabetes. The screening looks for a protein called albumin in the urine, which signals nephropathy.

For the last year, the CHI Saint Joseph Medical Group – Primary Care in Richmond has been working with CHI Saint Joseph Health Partners health coaches to drive screening for nephropathy. The practice has used teamwork to screen their patients with diabetes according to guidelines, using a team-based approach to drive overall quality of care.

How important is the office team environment in care management of patients with diabetes? What is your approach?

The entire office plays a role in caring for our patients and their needs. The Certified Medical Assistants review the patient’s historical labs, testing, and results before making the determination to perform the microablumin testing. The staff also reviews the patients and alerts to help with the determination to move forward with testing.

Has it been beneficial to have Health Partners health coaches working with your practice?

Our health coaches have been a great help to the facility. They help with guidelines, recommendations and education.

Do you have any tips for primary care practices to drive quality metrics around testing for nephropathy?

Microalbuminuria screening with a spot urine albumin/creatinine ratio helps detect early stages of nephropathy, because diabetic nephropathy may result from a decreased glomerular filtration rate (level of kidney function) of increased creatinine level. Due to these unique results, testing should be included in the annual monitoring of diabetes.

For more information on guidelines of care for patients with diabetes, see the CHI Saint Joseph Health Partners Quality Matters – Type 2 Diabetes and the National Kidney Foundation screening guide for microalbuminuria in patients with diabetes.