ProClarity Database Used to Improve and Manage Diabetic Patients

Purpose:
The ProClarity database is a system the VA staff use to assist providers with panel management. The purpose of this innovation was to track and trend high risk diabetics patients (those with HgbA1C>11 and no HgbA1C labs on record) were referred to home Telehealth Program.

Significance:
Diabetes is the leading cause of heart disease and stroke in the United States. The two groups were selected to identify trends. Teaching self management for these patients promoted positive outcomes and decrease cost for the institution such as fewer visits and medication usage.

Strategy and Implementation:
ProClarity database was used to identify the high risk group of patients monthly with elevated HgbA1C>11 and no study patients that did not have a current HgbA1C on record. Nurses consulted the Home Telehealth program and referred the patients with HgbA1C >9 for enrollment. Innovative strategies with the use of technology, case management and collaboration with the interdisciplinary team promoted self care management. Staff trained the patients on the use of the Health Buddy (computerized self management monitor) and monitored them remotely. Patients became active participants in their care. The treatment modality included: intensive case management, diabetes education, diet modification, exercise, and adherence to the plan of care. Patients were followed by the multidisciplinary team comprised of telehealth staff, nurses, pharm-d and the physician. As evidence by the monthly review of the HgbA1C, there was an increase in diabetic patient compliance.

Evaluation:
The HgbA1C levels for 100 patients were monitored for 18 months. The patient results were categorized as: HgbA1C>11, 8-10, 7-8, and 6-7. After referral to Telehealth, in six months, the patients migrated to a lower category which demonstrated better compliance and clinical outcomes.

Implications for Practice:
The ProClarity database and Intensive Case Management with Home Telehealth Program provided effective management for uncontrolled diabetics. This coordinated process may be useful to other clinics by utilizing a similar model to enhance patient compliance and quality care.