Integrating outpatient care the Toyota way: An individualized multidisciplinary team-care model for diabetes care delivery

Abstract

The Diabetes Clinic at VA Pittsburgh has been redesigned through an innovative systems-oriented approach to delivering integrated, multidisciplinary diabetes care founded on Principles of Perfecting Patient Care (PPCSM), which derive from Toyota Production Systems’ methods. The four elements of PPCSM (highly specified work content and sequence, unambiguous work flow connections, predefined pathways, and continuous process improvements based on scientific method) are incorporated into a model for delivering integrated multidisciplinary patient-centred care calibrated to each individual patient’s abilities, needs, preferences, and goals. The model, which we term the “Individualized Multidisciplinary Team-Care Model”, provides all the essential care elements in a multi-provider clinic visit comprising four sequential 15 min encounters with four providers possessing specific skills in DSME, MNT, BP and Lipid Management, and Glycaemic Management. Ongoing collaborative dialogue ensures that interventions are coordinated, calibrated to patient need and aligned with risk stratification. Documentation of all required care components is assured by templated component notes, which are assembled into a single, integrated, multiple-provider visit note in the electronic medical record. The clinic redesign has achieved unprecedented success, with 100 % documentation in ADA specified process-of-care domains in diabetes care (HbA1c, LDL, blood pressure, annual creatinine and urinary microalbumin levels, annual foot and eye exams, and aspirin and statin use/contraindications/alternatives). It has also achieved significant improvements in HbA1c (decreased by 0.6 %), LDL (<100 mg/dl [<2.6 mmol/l] in 90 %, compared to 75 % earlier), and SBP (<130 mmHg in 63 % vs 35 % earlier). In all instances of SBP >130 mmHg, or LDL >100 mg/dl there was documentation of action to intensify therapy, or the reason for inaction. The redesigned model can be adapted to a variety of needs, ranging from basic diabetes management, through more complicated management strategies, all the way up to the most advanced strategies for patients on insulin pumps. It delivers care that is both comprehensive and effective by combining the advantages of the established models (coordinated care emphasizing DSME and MNT of Group Visits and individualized attention in the Single Provider-Patient dyad) while eliminating their disadvantages (the impersonality of Group Visits and the fragmented inefficiencies of the Single Provider-Patient dyad).