ST. LOUIS – It’s a matter of life and death and dollars and cents: Diabetes is the eighth-leading cause of death in the United States, and those with the disease spend twice as much on medical costs.
To get patients healthier and to protect their pocketbooks, Mercy is using its electronic health record to identify patients with high blood sugar and get them moving toward better health.
“Our team works like ‘care traffic controllers’ to figure out what the barriers are for our patients so they can conquer their diabetes,” said Jennifer Gist, manager of Mercy’s diabetes care team. “We knew if we could help patients control this one thing, their overall health would improve immensely. In fall 2021 we developed an algorithm that could search our electronic health record and identify patients who needed extra help. Once it finds that person, we reach out and help them navigate their care.”
Larry Eddings of Willard, Missouri, has known for decades that he has type 2 diabetes, with his estimated average glucose reading, or A1C, getting progressively worse. In 2022, it rose to 9.4%, well outside the normal range of less than 5.6%.
“I was what you’d probably call a ‘non-compliant’ patient,’” he said. “Every time I went to the doctor, I’d hear the advice about eating right and exercising, but what I really heard was ‘don’t have any fun.’ I figured at age 69, I only have so many days left, and I want to enjoy them.”
That’s where Ashley Evans, a Mercy clinical pharmacist, intervened. “I don’t work in a pharmacy,” she explained. “I work in the clinic with the primary care team to help patients like Larry get on track with their medications. Our team ensures they’re taking the right meds and that they can afford it.”
Evans switched Eddings to a newer medication and got him signed up for a prescription assistance program. “As a retired pastor, I never could’ve afforded this on my own,” he said. Eddings sends in his glucose count every morning, which is monitored by his diabetes care nurse and sent to Evans in case a change is needed. As a result, he’s using less insulin and his A1C is down to 7.2%.
“I’ve lost 25 pounds, and I can’t keep my britches on,” he said. “I actually feel like there’s hope I might be able to get better instead of worse.”
For married couple Terri and Pat Weaver in Greenwood, Arkansas, the diabetes diagnoses were a bit of a surprise. Pat was diagnosed after a heart attack about 14 years ago, and his wife was in the hospital with breathing issues five years ago when she learned she had the disease. Both agree the accountability they get from April Wimp, their diabetes care registered nurse and education specialist, has made all the difference for them.
“I check my sugar every morning, because I know I have to submit a report,” Terri said. “It was hard to manage before April stepped in. I didn’t know what I was doing. She has worked with us and is really concerned about us.”
Pat agrees. “I’m really bad about falling off the wagon and eating things I shouldn’t eat,” he said. “There have been times my blood sugar has gone up and April has called right away. We talk through it, talk about what I’ve eaten and figure out how to make changes. She’s explained a lot of things about diabetes and food that I never knew. She truly cares about how we’re doing, and it has made me want to work harder to make her happy.”
The positive results are widespread. More than half the Mercy patients enrolled in the diabetes care model have achieved a reduction in their A1C levels and an average 5% weight loss. Those with A1C levels greater than 13 have dropped their readings an average of 21% – with half reducing it by an average of 44%.
Diabetes care coordination is just one example of how Mercy is using data to take a broad look at its patients’ health issues, and then reacting with personalized care to address individuals’ needs. Care teams can set the search parameters and even change them over time, allowing for flexibility to reach patients with the greatest needs. For diabetes, the automatic search built into Mercy’s electronic health record looks for patients with A1C levels greater than 9%. Once identified, the team reaches out to ask patients to participate in the program.
“We’re using technology to care for entire populations, one patient at a time,” said Dr. Gavin Helton, Mercy president of Primary Care. “We mine the data, find the opportunities and then work directly with our primary care teams and our patients to make a real difference. It was clear we had a large group of patients – those with diabetes – who could benefit from intervention. With this approach, we’ve improved the lives of individual patients and the health of the group overall.”
The Weavers are glad they accepted the extra help. “My sugar has gone down so much,” Terri said. “I felt horrid before, with bad headaches anytime my sugar went high. I just feel so much better.”