Multipronged Approach to Improve Diabetes Care Management in the Home Health Setting
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New care delivery models and approaches to integrated care have emerged across the country to reduce health disparity, improve outcomes, and address care delivery fragmentation. Home health agencies (HHAs) and the millions of homebound adults in the U.S. are often in the middle of this fragmentation. This article describes a multipronged quality improvement (QI) approach taken by an Illinois HHA to reduce variation and improve the care management of its diabetic population. The agency was experiencing variations in care that misaligned with the parent health system, inconsistent documentation, and higher than desired emergency department (ED) utilization, rehospitalizations, and percentage of patients discharged with fasting blood glucose (FBG) levels outside of their target ranges. A team was formed to identify system gaps of care and develop multipronged mitigating interventions. Based on available data, post-intervention the agency had a 29% increase of patients discharged with FBG levels within target range, and a 15.0% reduction in ED utilization. The agency did not improve its rehospitalization rate. The identified limitations that may have impacted project results include the short implementation period, limited timeframe patients are enrolled in home health, agency operational dynamics, and electronic health record (EHR) barriers.
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