referrals were primarily initiated at the
individual office sites and were attributed
to the active presence of educators at these
F Other measures of diabetes control also
improved, including the number of patients
getting necessary eye exams and screening
F The population health nurse was instrumental
in engaging noncompliant patients. Approximately 30% of patients were engaged as
evidenced by scheduled appointments.
In 2017, the hospital system acquired four
hospitals and their PCP offices, including an additional 60 to 70 providers at 20 additional sites.
The program was extended to all sites at various
times throughout 2017–2018, based on timing of
EHR installation. Many of these sites had been
in the program for less than six months.
Within a short time, data showed excellent
results at all sites with a steady decline of A1C
greater than 9% in Secondary Region 1 (39% to
19.5%), and Secondary Region 2 (42% to 23%)
(See Figures 2 and 3).
Providers submitted positive feedback.
“Since you first talked to us about how
to improve management of our diabetes
patients, our percent has improved from
76.8% to 85.5%! The fact that the curve
clearly starts to go up in March indicates
to me that your education has been a
“We all like the NP and the program very
well. This program is working well for us
and our patients also like it a lot.”
“The program is very beneficial. It has
helped guide my patient plans and
strengthened my knowledge for
Discussion and Adaptability
The comprehensive diabetes management
program provides other organizations with a
framework to improve diabetes care and glycemic control and to improve clinical outcomes in
the outpatient setting.
Based on the research, this program is unique.
No published literature on similar programs has
1. G. Xu, B. Liu, Y. Sun et al. 2018. Prevalence of Diagnosed Type 1 and Type 2
Diabetes among U.S. Adults in 2016 and 2017: Population-Based Study. The BMJ.
Accessed July 16, 2019 at bmj.com/content/362/bmj.k1497.
2. Centers for Disease Control and Prevention. 2019. About Diabetes. Accessed
July 16, 2019 at cdc.gov/diabetes/basics/diabetes.html.
3. M.P. Petersen. 2018. Economic Costs of Diabetes in the U.S. in 2017. American
Diabetes Association. Diabetes Care, March 2018. Accessed July 16, 2019 at
4. American Diabetes Association. 2019. Glycemic Targets: Standards of Medical
Care in Diabetes. Diabetes Care, 42(Suppl 1): S61–S70. Accessed July 16, 2019
5. A. Qaseem, T.J. Wilt, D. Kansagara, et al. 2018. Hemoglobin A1C Targets for
Glycemic Control with Pharmacologic Therapy for Non-pregnant Adults with
Type 2 Diabetes Mellitus: A Guidance Statement Update from the American
College of Physicians. Annals of Intern Medicine, 168( 8): 569–576. Accessed July
16, 2019 at annals.org/aim/fullarticle/2674121/hemoglobin-1c-targets-glycemic-
6. Centers for Disease Control and Prevention. 2019. Op cit.
7. Effect of Intensive Blood-Glucose Control with Metformin on Complications in
Overweight Patients with Type 2 Diabetes. 1998. UK Prospective Diabetes Study
Group, UKPDS 34. Lancet, 352(9131): 854–865. Accessed July 16, 2019 at ncbi.
8. D.M. Nathan, S. Genuth, J. Lachin, et al. 1993. Diabetes Control and
Complications Trial Research Group: The Effect of Intensive Treatment of
Diabetes on the Development and Progression of Long-Term Complications in
Insulin-Dependent Diabetes Mellitus. New England Journal of Medicine, 329( 14):
977–986. Accessed July 16, 2019 at ncbi.nlm.nih.gov/pubmed/8366922.
In summary, an organization needs to:
F Acknowledge the relevance of well-organized
outpatient diabetes care
F Provide administrative commitment
F Identify a strong physician champion
F Prioritize and incrementally implement
This health system possessed all these
attributes, which led to a successful enterprise
approach to improving glycemic control for the
The two most successful components of the
program were the physician-led discussions at
the PCP sites and the strong role the specifically
trained NP played in improving diabetes control.
A new NP may be hired; however, an existing
NP can also be identified at a PCP site and
trained to be a local diabetes expert to provide
care for complicated diabetes patients. The
system utilized both approaches.
Data sharing and transparency with providers
in a timely manner were particularly helpful in
the success of the program.
Renu Joshi, M.D., is
vice president, chronic
population health, and
chief of endocrinology,
UPMC Pinnacle in Harrisburg, Pennsylvania. Dr.
Joshi would like to thank
Robert Nielson, M.D.,
Medical Group, and
Cathleen Veach, M.D.,
chief quality officer,
Group, UPMC Pinnacle,
for their support, and
Helen Houpt, M.S.L.S,
and Karla Belton for their