Closing Gaps in Care with Clinical Guidance In Between Visits To the Doctor

Health plans across the country are strategizing ways to improve health outcomes and quality scores. According to Dr. Philip Finocchiaro, physicians and staff spend an average of 15 hours per week closing gaps in care and satisfying quality measures. However, with complex diseases like diabetes, questions tend to arise in between visits to the doctor. Despite these questions, many people with diabetes are too embarrassed to proactively ask for help. As a result, a large number of patients (40 percent!) end up falling off their provider’s care plan, leading to poor health outcomes and lower quality scores for payers.

In his article about building a successful quality improvement plan, Dr. Finnocchiaro notes that face-to-face clinical contact is the number one tool to close gaps in care, outranking mobile apps, patient portals, social media, or surveys. But, how do we give patients that essential face-to-face support when providers don’t have the time to call patients in between visits? One effective solution is giving patients one-on-one support with a remote clinician who has diabetes expertise, ideally a certified diabetes educator (CDE).

The CDE’s role is to position patients for success and empower them to independently manage their care plan. CDEs can proactively reach out to patients and build trust, so that patients feel comfortable expressing concerns. Because of their clinical knowledge and ability to build rapport with patients, CDEs often uncover barriers that are preventing patient success. Some patients are overwhelmed and forget their doctor’s exact instructions. Others are scared of injecting or are confused as to why they aren’t seeing results. By identifying issues, CDEs can guide patients toward success in situations where they would otherwise fall off their care plans and suffer from health complications.

One patient we worked with was at risk for complications because she was scared to call her doctor about her foot pain. She thought that, if she reported the pain, her foot would be amputated. The patient’s CDE reassured her and motivated her to call her doctor and get the support she needed to prevent further complications. 

Similarly, we spoke with a patient who was worried about her “out of control” blood sugars. Her CDE discovered that she was taking double her dosage of insulin. Her endocrinologist and primary care provider had each prescribed her an injectable separately without knowledge of one another and she was taking each as prescribed. Her CDE explained the situation and urged her to call her primary care provider to sort out the confusion.

Had CDEs not followed up with these patients outside of the doctor’s office, the result could have been catastrophic for the patient and the healthcare system. We all know that diabetes is a complicated 24/7 disease that’s difficult for people to manage. By providing patients with remote expert clinical support in between visits, we are not only lowering costs, but we are also saving lives.

The Fit4D solution scales CDEs to enable more patients to have access to a clinical expert between visits to the doctor. Learn more.

By Aviva Menche, Marketing Manager, Fit4D