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Diabetes: An opportunity for coordinated care


Dr. Joseph Black
"No other disease requires as much support and education for patients trying to manage their illness," says Dr. Joseph Black, a primary care physician at North Portland clinic.

Diabetes challenges patients, doctors and the health system. It's a chronic illness that can bring severe complications, sometimes requiring hospitalization. But timely, well-coordinated care can hold diabetes in check, helping people stay healthy and curbing costs.

"Diabetes is not a death sentence, but a life change," says Jim Darcey, 63, of North Portland, who lives with the illness. He began controlling his blood sugar levels with the help of a coordinated-care team at the Multnomah County Health Department's North Portland clinic.

Darcey learned to manage his diabetes by taking insulin - which he injects daily - and by improving his diet, getting more exercise and addressing his depression.

Diabetes afflicts an estimated 262,000 Oregonians. Untreated, it can lead to heart disease, kidney failure, high blood pressure, eye problems, nerve damage and foot amputations. In Oregon, diabetes contributes to 56,000 hospitalizations a year, at a cost exceeding $1.1 billion, a 2008 Department of Human Services report found.

"No other disease requires as much support and education for patients trying to manage their illness," says Dr. Joseph Black, a primary care physician at the clinic. One in six of Black's patients has diabetes.

The North Portland center started using the patient-centered approach to track patients with diabetes about two years ago. Two nurses help Black monitor patients' "bundle measures" - a computerized tally of blood sugar levels, hemoglobin, blood pressure and cholesterol - to make sure they remain in the "safe zone." Patients come in every four to six months, or more often if they're outside the safe zone. Doctors get regular "report cards" on how many of their patients meet the targeted measures.

The many complications of diabetes demand a team approach, Black says. "It doesn't just happen in the exam room with the doctor," he says. "It also involves nursing and outreach."

This approach combines several ideas central to Oregon's ongoing health transformation:

  • Team-based care, with doctors, nurses, social workers and medical aides in close collaboration.
  • Electronic health records, enabling caregivers to quickly check a patient's test results, allergies or medications without poring through a foot-high paper stack.
  • The "health home," a place for patients to go for primary care instead of just heading for the hospital emergency room.
  • "Bundle measures," which allow a care team to track each patient's health against specific, evidence-based goals.

Today, Oregon is working toward transforming the health delivery system in a way that better supports these kinds of innovative approaches. Learn more at www.health.oregon.gov.