Approaches to integrated diabetes care: United States: San Francisco

Abstract

In the US, the most important advance in integrated primary care for patients with diabetes and other chronic conditions has been the Patient-Centered Medical Home (PCMH) model. A major goal of the PCMH is to provide care that is coordinated and/or integrated across all elements of the complex health-care system (including subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (including the patient’s family and community-based services). The PCMH model includes multiple features aimed at better integrated care, including care managers/coordinators, patient registries, improved access, regular reporting of quality measures, patient access to electronic health information, and payment restructuring to support these activities. Patient participation in their care is now seen as an essential element of integrated care. Research has shown the increasing patient participation though education, self-management support and health coaching can improve patient care processes and outcomes for patients with diabetes. Realizing the potential of integrated care is particularly challenging for patients with diabetes in urban and rural underserved populations. Work at our institution (University of California, San Francisco) and the San Francisco Department of Public Health illustrates those challenges and has led to new and newly adapted approaches for providing integrated care, including health coaching, electronic referrals, automated telephone support, patient care teams registries of patients with diabetes, and practice transformation using the ten Building Blocks of High-Performing Primary Care model.