People with diabetes often have multiple co-morbid conditions with multi-organ system complications, and therefore an increased frequency of hospitalization. In order to effectively manage this chronic disease, and prevent hospital admissions, people with diabetes need to receive appropriate clinical preventive services, and engage in regular self-management behaviors.
Kingsbrook Jewish Medical Center in Brooklyn, an NCQA Level III Patient-Centered Medical Home, focuses on ensuring that each diabetes patient has continuous care with medical providers, and provides these patients with access to a continuous glucose monitoring program. Pre-visit planning, primary care provider follow-up, and standardized documentation have also helped improve the clinical management of these diabetic patients.
As a result of these coordinated efforts, Hemoglobin AIC levels, an indicator of diabetes control, improved by more than 11% for patients with uncontrolled diabetes over a six-month period across Kingsbrook's physician practices.