Tennessee ranks 5th highest across the United States in diabetes prevalence, with 13% (or 650,000) of adult patients having a diagnosis of diabetes and an estimated 250,000 patients going undiagnosed. Diabetes and its associated complications such as dialysis and heart disease not only negatively impact patients’ lives, but it is also costly. These complications can be avoided by ensuring better A1c control and guideline-based screening and health maintenance.  

Since 2019, VHAN has doubled the number of members with poorly controlled diabetes newly enrolled in our diabetes program (from 159 to 240 patients), representing members across all VHAN plans. We took the following steps to improve health outcomes and lower the cost of care for these high-risk patients: 

  • Implemented a high-touch care management program for patients with uncontrolled diabetes 
  • Developed and implemented a Diabetes Care Path, which includes a medication algorithm and health maintenance recommendations 
  • Distributed Gaps report to alert practices of patients with open diabetes gaps 
  • Developed several VHAN Hub member resources, including QuizTime, webinars, diabetes patient classes, shared decision-making resources, patient report cards and other patient education materials 
  • Improved data connections to better track A1c data for patients across network 

A Patient Success Story
Here’s one patient who received a tremendous benefit from VHAN’s diabetes program:

Danielle had an A1c measurement of 13.7% and a BMI of 31. Afraid of needles, she was uncomfortable with the idea of daily insulin injections. She was also having trouble planning and preparing healthy meals. A VHAN practice called upon the network’s care navigator team to help Danielle improve her health. In partnership with her primary care physician, the team worked with her on medication management to potentially avoid the need for insulin treatments. They also encouraged her to start using GLP1 to address satiety and weight-related concerns. 

Danielle was encouraged to monitor her blood sugar regularly and given a customized meal plan and walking program. Routine check-ins from a Care Navigator rounded out Danielle’s care plan. 

After six months of support, Danielle’s A1c had dropped to 6.1%, and her BMI was cut to 26. She reported how much more confident she feels in her ability to manage her diabetes and how much she appreciates being included in the decision-making progress with her care team.