Picture a woman with acute diabetes arriving at the emergency department at 2 a.m. Her blood glucose level is extremely high and she is experiencing chest pain. Upon ruling out a heart attack and seeing no sign of hyperglycemic crisis, the ED physician concludes the patient does not require acute care. He then pages the doctor on call to request that outpatient care be arranged.
The doctor receiving the middle-of-the-night call finds it impossible to schedule outpatient care at such an early hour; therefore, the patient is likely to go home without proper guidance on managing her diabetes. This, in turn, leads to return ED visits and hospital readmissions.
Marie E. McDonnell, MD, director of the Health Diabetes Program at Brigham and Women’s Hospital, was often the doctor facing the above scenario. Her solution was to develop a collaboration between the ED and the endocrinology clinic to make sure patients presenting in the ED with acute diabetes needs received rapid, diabetes-focused follow-up.
Dr. McDonnell first established a program of this nature at Boston Medical Center. After joining the Brigham in 2014, she set out to establish a similar program. Launched in 2017, Brigham and Women’s Faulkner Hospital’s Emergency Department Diabetes Rapid-Referral Program (EDRP) connects ED patients who have acute diabetes needs with the diabetes-focused clinicians in the Brigham’s Sleep Medicine and Endocrinology Center. Based on its success, the program was expanded to the main Brigham campus in November.
“The hypothesis is simple,” said endocrinologist Nadine E. Palermo, DO, associate director of acute diabetes care at the Diabetes Program. “Eliminating the barrier to scheduling diabetes-focused ambulatory care and preventing unnecessary hospitalizations for patients with diabetes should improve patient outcomes and reduce healthcare expenditures.”
Individualized Patient Education Is the Key
Under the Brigham’s EDRP model, the diabetes clinic sets aside about eight weekly slots for the ED to use for acute diabetes patients. In the ED, case managers can directly book appointments for appropriate patients within 48 business hours of discharge.
Visits to the diabetes clinic, which typically last 60 to 90 minutes, focus primarily on individualized patient education and secondly on medical management (including insulin initiation, if needed). Dr. McDonnell and her team have worked to streamline the approach to involve more members of the team, including the medical assistants and the licensed practice nurse, to start the patient interview and identify educational needs.
“It’s challenging to manage a chronic disease because patients have to be ready to make lifestyle changes and take their medications on time and consistently,” Dr. McDonnell said. “We’ve found that these patients tend to be ready, which makes them a wonderful population to work with from a clinician’s perspective. The immediate education that we deliver through this program sets them up for success moving forward.”
Dr. McDonnell added that about 30 percent of patients are seen at the EDRP only once for an intensive 90-minute visit before returning to their usual care, while about 70 percent (especially those who start an injectable therapy) are seen at least twice. Of those in the latter group, she said, “about half will follow up with their PCP and the remainder will continue in the Brigham Diabetes Program due to their clinical complexity.”
A Significant Drop in Average A1C
The EDRP has shown impressive results. Most notably, in an analysis of the first 60 patients seen at Brigham and Women’s Faulkner Hospital in 2018, the average A1C dropped from 10.9 percent to 7.3percent, in the subsequent year, a remarkable achievement that is associated with outcomes such as improved mortality. In addition, over 80percent of our EDRP patients began or continued care with a primary care physician or diabetes clinician. (Readmission rates for the program will be determined as part of an analysis in 2021.)
Dr. McDonnell cited reduced administrative burden as another benefit. “You’re giving the ED access to your clinic schedule,” she said. “The EDRP is demonstrating that this can work, that it doesn’t interrupt your flow as long as you prepare for it. In fact, it becomes a significant team-building practice.”
“The idea is, we take the ED’s responsibility of transitioning their patients safely to outpatient care,” she added. “It’s a real handshake—you send me your patient, and we’ll take care of them. That kind of model doesn’t exist enough in diabetes care, to be honest.”
Growing Pains to Be Expected
Based on her experience, Dr. McDonnell had these lessons to share for endocrinologists:
- Team members must be highly skilled in both medical management and inpatient education.
- There must be broad awareness so that the program “becomes woven into the fabric of the hospital.”
- The hospital must be willing to subsidize a follow-up visit to the diabetes clinic for uninsured patients who meet EDRP criteria, as this reduces readmission rates.
“Also, implementing this model takes time,” Dr. McDonnell cautioned. “But once the systems get going, say after six months or so, you’ll find it’s a very inspiring patient population and care model, and your team will love it.”