Incorporating Diabetes Care Into a Health Maintenance Organisation Setting: A Practical Guide

This article describes 3 approaches to improving diabetes care in a health maintenance organisation (HMO) setting. The first approach was to identify which patients had not received a dilated eye examination in the past year, notify both them and their physician, and provide each with information concerning its importance, as well as providing the physician with the means to easily communicate with the patient. The results were a disappointing modest and transient increase in dilated eye examinations, which returned to the baseline rate after a few months. The second approach was to provide the primary care physician with an agreed set of guidelines along with the status of the patient in meeting these guidelines at the time of the visit. This resulted in compliance with these guidelines only one-third of the time. In contrast, the third approach, provision of diabetes care by nurses following detailed algorithms supervised by a diabetologist, resulted in improved glycaemic control, lowering of elevated cholesterol levels and increased eye and foot examinations compared with patients with diabetes followed in other HMO settings. Furthermore, the rate of hospitalisation for acute diabetes problems (i.e. metabolic diabetes problems, infections) was only one-quarter of the national average in the patients managed by the nurses.