Improving Care for Patients With Diabetes at a Rural Primary Care Clinic by Empowering Licensed Nursing Assistants With a Flow Sheet Tool

C hronic diseases such as diabetes are among the leading causes of illness, disability, and death in the United States, affecting nearly half of the population. They account for the majority of health care expenses.1 Most of the expense from diabetes is from micro- and macrovascular complications such as heart attacks, kidney disease, and eye disease.2,3 Evidence-based measures that can prevent and slow the progression of these complications are summarized in the American Diabetes Association clinical practice guidelines.4 Studies have shown that health care providers routinely fail to follow these recommended guidelines for patients with diabetes, fulfilling all recommended guidelines only 45% of the time.5 Further studies have found that this failure frequently results from inadequate systems to support health care delivery for chronic conditions.6 The Dartmouth-Hitchcock Lyme Clinic is an extension of the Section of General Internal Medicine at Dartmouth-Hitchcock Medical Center in Lyme, N.H. It has a patient population of 4,500. The clinic specializes in adult preventive care and the management of common, complex, and chronic medical conditions. Diabetes affects 8-10% of the clinic population and is its sixth most common diagnosis group. At baseline, only 73% of patients with diabetes visiting the clinic were receiving pneumococcal vaccinations, and 16% were receiving foot exams. The global aim of the effort described here was to redesign the routine care received by patients with diabetes at the Dartmouth-Hitchcock Lyme Clinic to make the care more evidence-based and reliable. There were two specific aims: 1 ) to identify all patients with diabetes every time they visit the clinic and 2 ) to improve performance and documentation of recommended process measures. The clinic's licensed nursing assistants (LNAs) and physicians were primarily engaged in this improvement initiative, which was the first clinic-wide improvement project at the Dartmouth-Hitchcock Lyme …