Improving the Overall Quality of Care for Patients Diagnosed with Diabetes Mellitus and Hypertension

Background:

Saint Peter’s University Hospital applied for funding from New Jersey’s Delivery System Reform Incentive Payment Program (DSRIP). DSRIP is one component of the state’s Comprehensive Medicaid Waiver, as approved by the Centers for Medicare and Medicaid Services (CMS). It is a demonstration program designed to result in better care for individuals (including access to care, quality of care, and health outcomes), better health for the population, and lower costs by transitioning hospital funding to a model where payment is contingent on achieving health improvement goals and benchmarks.

Community Need:

The joint Community Health Needs Assessment, conducted in 2012 by Saint Peter’s University Hospital and Robert Wood Johnson University Hospital, along with community partners, demonstrated that diabetes and hypertension are two of the most prevalent health issues affecting the residents of central New Jersey. More than half (56.2 percent) of adults surveyed were diagnosed with at least one chronic condition, and 30.8 percent were diagnosed with high blood pressure. According to the assessment, diabetes is more prevalent in communities with a noted concentration of Latino, African-American and South Asian individuals. Diet, obesity, age, disease, stress and even smoking are believed to contribute to the onset of diabetes.

In addition, approximately one-quarter of residents in the survey reported at least one major barrier to wanted care and more than half reported difficulty navigating the healthcare system.

Description of the Proposed Project:

Saint Peter’s developed and implemented a patient-centered medical home resulting in an improved overall quality of care. Patients diagnosed with diabetes mellitus and hypertension who were uninsured or under-insured would be served. Patients are entered into the program via ambulatory care (outpatient) services, the emergency department, inpatient services, same-day service locations, and community health screenings conducted by hospital staff. The program includes use of multi-therapeutic outpatient evidenced-based management; lifestyle modification, nutritional consultation, intensive hospital discharge planning, a dedicated patient navigation system and improved social services.

Care improvement is accomplished through addressing both medical and social care needs in a comprehensive, holistic manner. Care team members will include physicians, advanced practice nurses, registered nurses, social workers/case managers, nutritionists, and transition coaches with care organized and coordinated to achieve our project outcomes.

Desired Project Outcomes:

  1. Reduce admissions
  2. Reduce emergency department visits
  3. Improve care processes
  4. Increase patient satisfaction.

The Thyroid and Diabetes Center is another community-based service of Saint Peter's Healthcare System.

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