Effects of Scheduling Diabetic Patients with HgbA1c Values of 7.1% or Greater after Co-Appointment Visits with Their Primary Care Provider and a Dietitian
Charmayne Tyler-Jackson, RN, BSN, MSN/Ed ('73) and
Deirdre Johnson Reid, MS, RD ('90)
Syracuse University Graduates
Employed at the DC VAMC
(District of Columbia Veterans Administration Medical Center)
Greenbelt CBOC (Community Based Outpatient Clinic)
Charmayne Tyler-Jackson, RN, BSN, MSN/Ed and Deirdre Johnson Reid, MS, RD, Syracuse University graduates, both work in the District of Columbia Veterans Administration Medical Center (DC VAMC) Greenbelt Community Outpatient Clinic (CBOC). Greenbelt CBOC is located at the intersection of the MD 193 and the Baltimore-Washington Parkway (MD 295). This clinic covers basic medical care for veterans in the Northern Prince Georges County, Montgomery County, and Northeast portion of Washington, D.C. (U.S. Department of Veterans Affairs, 2009). Tyler-Jackson, RN and Reid, RD noticed in 2008 that their clinic had a large number of diabetic patients with levels of glycosylated hemoglobin (HgbA1c or A1c) above 7.1%. HgbA1c monitors the average levels of glucose over 90 days. The nurse and dietitian goals were to lower A1c values of their diabetic veterans through co-appointments with the primary care providers and the dietitian. The purpose of scheduling co-appointments was to expose the veteran with increased education, awareness and impart needed skills to better manage their diabetes through nutrition intervention. A1c levels of greater than 7% can result in increased chances for kidney disease, nerve damage, and eye disease (New Jersey Medicare Quality Initiative, 2003).
In 2010, the DC VAMC, set goals that 21% of their clients would have an A1c of less than 9%. However, only 17% of the DC VAMC veterans had an A1c of less than 9% in 2010. (Washington, DC Veterans Affairs Medical Center, 2010).
In 2009, it was found that the CBOC exceeded all of the main hospital quality measures except for diabetic foot and retinal examinations. As of October 1, 2008, there were no performance improvement measures in place to measure A1c levels, (Department of Veterans Affairs Office of Inspector General, 2009), therefore, the Syracuse graduates initiated this performance improvement project in their community clinic.
The DC VAMC cares for over 50,000 veterans in the DC, Maryland, and Virginia region. There are approximately 500,000 outpatient visits per year (U.S. Department of Veterans Affairs, 2011). Two-hundred, twenty of the physician's patients had a diagnosis of diabetes and eighty-nine of these clients had an A1c of greater than 7.1% as of September 30, 2009.
One-hundred, sixteen of the other medical providers and a nurse practitioner have diabetes diagnosis with thirty-eight of them having values of greater than 7.1% (U.S. Department of Veterans Affairs, 2011). Having a dietitian, who is a nutrition expert, at the CBOC is advantageous to the patients due to the skills obtained and the increased awareness of diabetes and obesity in the U. S. (Bureau of Labor and Statistics, 2010).
October 1, 2008 Tyler-Jackson and Reid started their performance improvement study of co-appointments with provider and dietitian of diabetic clients with A1c levels over 7%. Nineteen patients were chosen for the study. Eighteen agreed to be monitored in the study. Seventeen were patients of the physician and one of the nurse practitioner. One patient expired prior to September 30, 2009, which was before the end of the study.
The performance improvement study results indicated that 50% of the clients whose A1c was greater than 7.1%, who had co-appointments with the medical provider and the dietitian, resulted in decreased levels of their A1c levels after one year. It was decided that any lowering of blood sugars is beneficial to the clients of the Greenbelt CBOC. Since the conclusion of the study, the clinic has also begun to include a co-appointment for those patients with Cholesterol levels of greater than 200 and Body Mass Index (BMI) of greater than 30.
