Innovating The Nurse Practitioner Role in Chronic Disease Management

In a special Health Affairs report, Rachel Garfield, PhD, of the Kaiser Commission on Medicaid and the Uninsured, and Anthony Damico, PhD, of the Kaiser Family Foundation, determined that Medicaid’s role in covering the population with diabetes will grow in 2014 when additional low-income, uninsured adults gain eligibility for the program under the Medicaid expansion provisions of the Affordable Care Act.

In a special Health Affairs report, Rachel Garfield, PhD, of the Kaiser Commission on Medicaid and the Uninsured, and Anthony Damico, PhD, of the Kaiser Family Foundation, determined that Medicaid’s role in covering the population with diabetes will grow in 2014 when additional low-income, uninsured adults gain eligibility for the program under the Medicaid expansion provisions of the Affordable Care Act.  Since the total annual per-capita health spending on adult Medicaid patients with diabetes was more than three times higher than spending on beneficiaries without diabetes ($14,229 versus $4,568), this could be a disturbing statistic for North Texas residents.  Using data from the CDC, the Institute for Alternative Futures Diabetes model estimates that diagnosed and undiagnosed diabetes cases in this region are expected to rise 78 percent between 2010 and 2025, when the total is projected to exceed 1.5 million.  Sobering, indeed.

While Type 1 diabetes involves a malfunctioning pancreas, Type 2 diabetes develops when one’s own insulin becomes less efficient at moving sugar out of the bloodstream.  Both can be associated with obesity, high blood pressure, cholesterol and depression and are often undiagnosed in the presence of other common complications such as eye, kidney, lower extremity and heart damage.  For the good news, both types can be managed with appropriate drug regimens and lifestyle modifications.  As noted in the ISA report, future diabetic reductions depend upon the promotion of targeted screening for asymptomatic adults, improved access to quality medical care and increased patient compliance with therapy.  Halting the “twin epidemics” of diabetes and obesity will also require greater access to opportunities for physical activity in schools, workplaces, and communities and a significant shift in the American diet away from sugar, salt, refined carbohydrates and saturated fats and toward more fruits and vegetables.

With the North Texas regional diabetes societal and medical related costs already set to balloon 87% between the years of 2010 and 2025, one has to wonder how the pending Texas Medicaid changes will affect this?  Expansion or not, creative healthcare providers have the opportunity to improve this frightening situation.  As Suma Health System discovered, nurse practitioners employing the Chronic Care Model, including the use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, can improve processes of care and clinical outcomes for this population.

Coupling the activities above with on-site patient education via tablets and additional patient-centered technology beyond the clinic walls, similar to this Southeast Minnesota Beacon initiative, improves engagement and therapy adherence, strategic elements for stage 2 meaningful use demonstration.  Partnering with other healthcare organizations to create green, sustainable buildings for delivery of primary care, psychosocial and wellness services in underserved areas also presents a tangible opportunity to prevent future diabetes development.   Utilizing roof space to install an urban garden and jogging track for inner city or landlocked destinations represents a creative solution for a commitment to physical fitness.  And working with nutritionists and local farmers markets to educate and deliver healthy food choices takes the community one step closer to improving access to care, preventing re/admissions, and reducing prevalence and associated cost of this potentially dilapidating disease.  With a veteran diabetes provider and acute care nurse practitioner in the role of President, Health Care & Education at the American Diabetes Association, is there no better time to illustrate this innovative role for NPs in managing chronic disease?