by Candi Helseth
In Monticello, Ill., a lot of Kirby Medical Group (KMG) patients are feeling really good these days. Eighty percent of 386 diabetic patients being monitored in a KMG clinical care coordination program begun in March 2009 have substantially lowered their average A1C (blood glucose) levels. In addition, more than 400 patients have lost over 15,000 pounds in Fresh Start, a medically supervised weight loss program KMG began in August 2010.
“The success has been phenomenal,” KMG Director Val McCann said. “Diabetes and obesity are two of the highest volume diseases we see in our clinics and because they typically go hand in hand, we saw a weight loss program as a proactive approach to reduce obesity associated with development of diabetes. It’s also a way to help our Type 2 diabetics gain better control of their disease if they choose to participate. We had one patient on three different insulins who was able to drop all of them within 30 days of beginning this weight loss program.”
Patient Connie Caveny lost 120 pounds after being told she was pre-diabetic. Caveny’s blood sugar levels are back in the normal range and she no longer needs blood pressure medication. Nurse Practitioner Amber Oberheim said 80 to 90 percent of patients on medications have reduced or eliminated their meds by the time they reach their goal weight.
“I was a buffet for every germ, fungus and bacteria that came along,” Caveny said. “Toenail infections, leg spots that wouldn’t go away, tingling shins, but the scariest part was when they told me I was pre-diabetic. All of that is good now.”
Known complications from diabetes include heart disease, stroke, blindness, kidney disease, neuropathy and amputations. Better diabetes management can prevent or delay complications, according to the American Diabetes Association. McCann said KMG’s clinical care coordination for diabetes management includes 94 percent compliance for annual cholesterol testing, 76 percent compliance for micro albumin testing every six months, 94 percent compliance for annual eye examinations and 92 percent compliance for annual foot examinations.
Full-time Clinical Care Coordinator Kelley Palmer, a registered nurse, oversees the clinical care coordination program. Working with patients’ physicians and other providers, she educates patients, monitors their progress, provides feedback to medical staff and coordinates each patient’s care to ensure consistency.
“Patients are non-compliant for a multitude of reasons, whether it be financial reasons, forgetfulness, time constraints, denial, fear, etc.,” Palmer said. “Our job is to make sure that we communicate with our patients on a regular basis so we can determine why they are non-compliant and come up with solutions to help them. Without monitoring and follow through, everyone is in the dark. The providers and patients also get the most out of their visit when all the testing is up to date and available at the time of the appointment.”
Denial and resistance are particularly common among men and young adults who require more intensive monitoring for good management, Palmer said. Generally, though, the more thoroughly patients understand their disease process, the better they respond.
“Prior to Kelley joining the clinic, there was minimal coordination of care and minimal education provided to our patients due to staff time constraints,” McCann said. “We wanted to establish consistency in the care of chronic disease regardless of who was treating the patient in our clinic. We decided to develop protocols and begin to implement processes that would improve the overall quality of care with chronic disease management.”
In addition to diabetes management, KMG has expanded the clinical care coordination program to include outpatient addiction medicine and anticoagulation management. McCann, who conducts research on patient and community needs before developing and implementing new protocols, is currently developing a protocol for hypertension management.
Fresh Start, which is separate from the clinical care coordination program, enhances patient clinical care outcomes. Patients on Fresh Start follow a carefully supervised normal protein, low carbohydrate meal plan that includes pre-packaged food items, fresh vegetables and lean protein along with lifestyle management techniques such as beginning an exercise program and learning to make healthy food choices. Once they reach their goal, patients continue on a structured maintenance plan to help them make their lifestyle changes new habits that will ultimately result in maintaining their weight loss.
“They are helping a lot of people with these programs,” Caveny said. “There were a lot of things I couldn’t do any more. I couldn’t carry my grandkids. I had trouble going up and down the steps in our farmhouse. My orthopedic doctor told me it wasn’t if, but when, that I’d need a knee replacement. My life is so much better now.”
Kirby Medical Groups operates clinics in Atwood and Monticello. The John and Mary E. Kirby Hospital in Monticello owns the clinics. The regional center serves about 20,000 patients annually in Piatt and Douglas counties.
To learn more, contact KMG Director Val McCann at 217-762-6320.
Back to: Summer 2011 Issue