It takes a village: Clinic uses team approach in caring for diabetes patients

November 16, 2020

When it comes to treating a disease that one out of every 10 of your patients has, the name of the game is teamwork.

At Venice Family Clinic, we treat patients with diabetes using a team-based approach that encompasses primary care, health education, vision and pharmacy to ensure all facets of diabetes care are covered.

“The alternative is really dire,” said Dr. Despina Kayichian, chief medical officer at Venice Family Clinic. “If you don’t control diabetes, you can become blind, be on dialysis or lose limbs. These are horrible health consequences. We cannot let this be the natural course for our patients. We cannot overlook our responsibility to focus on this disease and remove barriers to care.”

On that front, the Clinic has been focusing on patients with uncontrolled diabetes, which means they have a hemoglobin A1c level (a test that reflects average blood glucose concentration for the past 3 to 4 months) above 9%. This is a very high level; the American Diabetes Association recommends keeping it below 7.0%. For the past six years, with support from the Leonard M. Lipman Charitable Fund, Venice Family Clinic has been enrolling between 250 and 300 patients at a time into a management program, where coordinated care and frequent contact from nurse practitioners specially trained in diabetes care have successfully helped patients lower their blood glucose to safer levels.

“Diabetes can be devastating, and complications can destroy a population,” said Dr. Mayer Davidson, Venice Family Clinic’s founder and world-renowned diabetes specialist who designed the Leonard M. Lipman Diabetes Management Program based on his previous successes with this model at UCLA Health, Cedars-Sinai, City of Hope and Los Angeles County. “Most people with diabetes are cared for by primary care physicians. But they often don’t have the time, and many the experience, it takes to treat diabetes effectively. So we refer patients who are in poor control of their diabetes to our Lipman program in order to have the most impact.”

How it works 

According to Dr. Davidson, there are three keys to success in a diabetes management program: clinicians who are trained to make appropriate clinical judgements, a team-based approach, and more frequent interactions with the patient.

At the program’s core is a dedicated two-person care team, or a dyad, that includes a highly trained nurse practitioner and a health educator. The nurse practitioner and health educator spend more time and check in with patients in this program more frequently than in traditional models of care, providing an extra layer of patient support.

The health educators assist with case management, medication reconciliation and glucose monitoring, calling patients as often as every two weeks to ensure they are on the right track. Health educators also teach patients how to use their glucose-reading machines at home so when they call, patients can provide their glucose levels, enabling clinicians to make adjustments to medications in between visits. 

The results of this program are impressive. After spending a year in the program, 91% of patients have been able to lower their A1c levels below 7.5%. In a more traditional model of care, very few patients this poorly controlled have been able to achieve similar results.

Being part of a team

The Clinic’s vision and pharmacy services are also integrated into diabetes care.

We have a full-time optometrist, Dr. Keith Simon, who evaluates patients for diabetic complications of the eyes. “Diabetes is the No. 1 cause of blindness in working-age adults,” he said. “Vision services is here to reduce the likelihood of our patients becoming part of that grim statistic, as part of a collaborative team.”

The Clinic’s Vision services also provide retinal photos to screen for diabetic retinopathy. The visits for these photos are relatively short and can be done by appointment, or they can be arranged while the patient is being seen at the Clinic for another purpose.

When it comes to making sure our patients get the medication they need to manage their diabetes, our Pharmacy department helps make that happen. Insulin, oral medications, and glucose meters and strips are expensive and aren’t easily accessible to the low-income communities our patients come from. Our pharmacists help patients determine what their insurance covers and ensure they receive the medications they need at an affordable price.

“We genuinely care for the patients here,” said Sharon Ng, director of pharmacy at Venice Family Clinic. “Our diabetes program allows us to get to know each other one on one, making it easier to understand patients’ needs.”

Educating patients

In addition to the work with our Lipman program patients, the Clinic’s Health Education department offers all patients diagnosed with diabetes individual consultations, group educational meetings about diet and lifestyle, cooking demonstrations, and exercise classes.

“We’re able to explain what the patient is going through at a level the patient understands,” Director of Health Education Rigo Garcia said. “When someone is diagnosed with diabetes, sometimes they’re left in shock. They know it’s going to change their life. Our health educators give that patient the time to ask lots of questions and walk them through what it means to have a specific diagnosis like diabetes.” 

For example, our Health Education department worked with “Marcia,” who was diagnosed with type 2 diabetes with an A1c level of over 11%. She was confused and upset about the diagnosis, and was even referred to our Behavioral Health program for depression. However, our health educators were able to work with Marcia to explain the illness itself, what she needed to do to control it and convinced her to take part in diabetes, cooking and exercise classes. Marcia was resistant at first, thinking she was “too fat” to join our group exercise classes, but we assured her that people of every fitness level were welcome. Marcia’s A1c level is now at 7.8%.

What comes next

Dr. Kayichian’s goal is for the nurse practitioners who are part of the Lipman program to share their knowledge with the rest of the Clinic, as well as to expand the Lipman program to include more patients.

To that end, Dr. Kayichian leads a monthly diabetes work group that includes the two nurse practitioners, Ligaya Scarlett and Katie Asmuth, and two health educators, Jessica Goldberg and Vanessa Marcial, in the Lipman program; as well as Dr. Davidson; Rigo Garcia from Health Education; Dr. Rian Rutherford, a physician champion; Meghan Powers, the Clinic’s director of quality improvement; Gabriella Villalobos, a population health coordinator; and Trevor Oelrich, a clinical pharmacist. The group focuses on improving metrics around diabetes care across the Clinic, ensuring we’re doing all we can to help our patients. Dr. Kayichian also invites the Lipman program nurse practitioners to present regularly at Clinic-wide provider meetings.

Soon the Clinic will have technology that will allow clinicians to check patients’ A1c levels during their appointments and get rapid results while the patient is still on site. And diabetes providers will soon have access to software that will allow them to read glucose meters remotely and adjust medication dosing without patients needing to come in to the Clinic, something that’s important for high-risk diabetes patients during the COVID-19 pandemic.

The multidisciplinary teamwork that it takes to achieve results among diabetes patients is an ongoing process at Venice Family Clinic, one that the Clinic is dedicated to pursuing.

“Look how engaged we are in taking care of people with diabetes – that doesn’t happen in very many places,” Dr. Davidson said.