Improving Self-Management for Patients with Diabetes

Venice Family Clinic

Venice Family Clinic (VFC), located in Venice Beach, CA, serves over 24,800 patients across 10 clinical sites. Many of its patients are non-English speakers. As a TCPI practice, VFC works closely with the Los Angeles Practice Transformation Network (LAPTN) to improve care and reduce costs. One identified focus has been improving timely monitoring and follow-up care for patients with uncontrolled diabetes. VFC’s goal was to increase the number of follow-up appointments scheduled and completed in a timely fashion. The Clinic used a variety of outreach methods (e.g., generic letters, messages in the patient portal, cold calls) but wanted to develop a new process that was both efficient and effective in meeting its goals. A review of the data revealed that few patients who were sent messages via the Patient Portal opened them and scheduled an appointment. The written letter response rate was slightly better, but was insufficient to achieve Clinic goals.

After participating in a PFE Metrics webinar exploring the role of health literacy in patient engagement, a small team from VFC, consisting of the QI Consultant, QI Director, Population Health Coordinator and Health Education staff, formed a working group. They solicited input about the process from other stakeholders, including clinicians. As a result, they created a customized, patient friendly letter that utilized colorful graphics and personalized A1c information with a request to contact the Population Health Coordinator to schedule an appointment. Using the traditional stoplight color-coding, A1c scores helped patients understand why follow-up was needed. Letters were written for both English and Spanish speakers and mailed along with a calendar listing the Clinic’s nutrition and exercise classes. In the pilot period using the new letter, 39% of both patient groups (English and Spanish-speakers) scheduled and kept follow-up appointments.

Before expanding beyond the pilot phase, patient interviews were conducted to learn what had been most useful and had spurred action by patients. The feedback confirmed the letter was seen as a personal request by patients’ doctors and helped them to understand what their A1c results meant. Additionally, the direct request to contact a specific individual was compelling.

Based on the pilot results, the letter and new process have become standard practice in the Clinic. Outreach/follow-up letters are now scheduled and sent to patients, using a batch file system, diabetes registry data (including last follow-up appointment and A1c levels), and the new letter template. As patients schedule their appointments, clinicians actively refer them to supportive services including diabetes education sessions, exercise and nutrition classes (Teaching Kitchen). By monitoring clinical outcomes over time, Venice Family Clinic will be able to capture the full impact of this new process for patients with diabetes, including changes in A1c levels as well as participation in programs designed to increase their knowledge, skills, and confidence in self-management.