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Triple Aim Lessons Learned: Improving Diabetes Care in Brazil

By Andrea Gushken | Monday, February 26, 2018

Improving Diabetes Care in Brazil

To address the nearly 10 percent prevalence of diabetes in Brazil, the Latin America team of the Institute for Healthcare Improvement (IHI) has been helping to build the improvement capability of the country’s local leaders, Ministry of Health, and hospital systems to improve diabetes care.

Andrea Gushken, MD, is a pediatrician, improvement specialist, and IHI faculty in Brazil who has analyzed the system in which patients receive care for diabetes. She and an improvement team from a primary care center decided to use the science of improvement to make drastic changes at Unimed Guarulhos, a large private health insurance company in Guarulhos based in the Southeast region of Brazil.

Before the first phase of interventions in 2013, the system was a “chaotic mess of specialists” who delivered fragmented care, according to Gushken. At Unimed Guarulhos, Gushken saw an opportunity to use the Triple Aim to redesign the system so it would be centered around the patient, while lowering costs and improving the care experience.

The driver diagram for this system recreation focused on three key areas:

  • Structure (especially patient flow)
  • Culture (especially staff and patient engagement)
  • Strategic coordination of information

The Shared Plan Card is a prime example of this redesign. Each patient with diabetes carries this card with their personalized diabetes plan, including the goals they’ve set and space to record their data. This has helped improve patients’ understanding of their care and the health care system, and empowered them in their journey with diabetes.

Shared Plan Card

Patients with diabetes also receive home visits, which has helped to humanize the patients’ care experience. Nurses and other health care professionals from a primary care center coach patients on their diet and use of medications. They help ensure that patients understand how to care for themselves at home and have adequate support.

Over the last four years, Unimed Guarulhos has expanded the diabetes program to all their patients with diabetes. At the end of September 2017, a total of 548 patients were in the program. In 2013, none of the institution’s patients were receiving what they consider “perfect care,” i.e., 10 minimum care components checked annually to prevent complications. These include waist circumference, body mass index, blood pressure, glycated hemoglobin (HbA1c), Low Density Lipoprotein (LDL), microalbuminuria, creatinine, eye exam, smoke cessation, and foot exam. Now 49 percent of patients with diabetes receive complete care.

Unimed Guarulhos also reports seeing a decrease in the cost of ER and hospitalizations for patients with diabetes in the last four years. The mean ER per capita costs decreased 59 percent (from R$127.60 to R$51.90) and the hospitalization per capita costs decreased 44 percent (from R$516.18 to R$290.90). 

While the processes implemented over the last four years are still in place, Gushken is not satisfied. She is committed to sustainability and continuous improvement. “The data says it all,” she notes. “Even with drastic improvements, the stagnation that is happening must be addressed with further engagement with patients and an increase in the engagement with the medical specialists.”

Despite the many challenges ahead, Unimed Guarulhos is a bright spot for diabetic care in the region. The team in Brazil has reimagined diabetic care by centering it around their patients. But they want to do more. “In order to activate a culture of continuous improvement,” Gushken says, “we must keep checking and rethinking our processes.”Number of patients in the diabetes program

Patients receiving perfect carePatients receiving "perfect care"Hospitalization costs per capita

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