Like many other countries in the world — including the United States — the Mexican health system has been facing an alarming increase in diabetes in recent years. Despite major advances toward universal health coverage, it is estimated that about 50 percent of the patients living with diabetes have not been diagnosed because it often takes years to develop symptoms and the health care system in Mexico has historically focused on treating communicable diseases. Now, however, the government and health care institutions in Mexico have prioritized prevention, early detection, and management of diabetes and its complications as part of its national health plan.
With the help of the Institute for Healthcare Improvement (IHI), the Ministry of Health (MoH) in the state of Campeche is building the quality improvement (QI) capability of local leaders and frontline staff to improve diabetes care delivery. Participants of the Ciencia de La Mejora en la Practica (Improvement Science in Action or ISIA) course held in Mexico last year used QI methods and tools to develop patient-centered strategies that achieved tangible results, contributed to creating a new strategy to improve diabetes care in the region, and developed competencies and skills they can apply to future QI initiatives.
Home Visits Make a Difference
In the state of Campeche, the local MoH invited IHI to help them develop the QI skills of 75 people on 15 teams. Seven teams focused on improving diabetes care and clinical outcomes. Cesar Lopez Rodriguez, MD, who works as a physician at the primary health center in Carmen, attended the ISIA course. His team worked on improving clinical control for the nearly 500 patients identified with type 2 diabetes within their catchment area. They focused on reducing no-show rates, improving follow-up visit attendance, and increasing the percentage of patients who get their HbA1c tested when indicated.
According to Lopez, their QI project sought to offer the “humanization of the patient and patient engagement” he considered missing from the diabetes care process at his clinic. They did this by providing targeted home visits to the individuals that had missed clinical appointments in the previous six months. During these home visits, the team members provided patients with information on diabetes and its symptoms and complications, and on how to manage their diabetes at home.
Initially, Lopez explained, many of the patients “didn’t even acknowledge that they had a chronic illness” because of the stigma around disease. The person-centered strategies the team used during the home visits helped patients more fully understand their illness, and conveyed the caring of the clinic staff. This project also helped the clinic staff appreciate their patients’ context, including social and economic barriers to filling their prescriptions or to attending their appointments.
Their approach achieved impressive results. After only five months of work, from May to October, they saw an 18 percent decrease in the no-show rate from a baseline of 38 percent. The percentage of patients under clinical control (HbA1c ≤ 7) increased from a baseline of 23 percent to 50 percent. Most dramatically, the percentage of cancelled appointments decreased from 39 percent to 0 percent.
Building Trust to Improve Care
In Lerma, Campeche, Miguel Alberto Canul Ruiz, MDI, is leader of the Lerma Community Health Center improvement team. His team’s goal was to increase the percentage of patients with diabetes attending their clinical control visits from a baseline of 24 percent to 80 percent between July and November of 2017.
To do this, they focused on creating a positive and meaningful relationship between patients and providers. They did this by establishing direct communication channels that helped the clinical team follow-up with patients, but also allowed patients to get information and provide feedback quickly. The tested the following change ideas:
- Using free instant messaging apps to send reminders to patients 24 hours before their appointments;
- Mapping the location of the patients with uncontrolled diabetes and doing targeted home visits to those with missed appointments;
- Developing a card with healthy eating tips to provide during home visits; and
- Using appointments as strategies to bring uncontrolled patients back into the system.
Home visits, an approach that centered on patients’ needs and local context, helped build trust between patients and providers, and helped providers better understand the challenges patients face in attending health visits and adhering to diabetes treatment. Canul and his team also conducted motivational and nutrition workshops to offer health education and exercise tips, and to help patients develop personal plans for how best to self-manage their diabetes. Making genuine human connections and providing individualized and person-centered care helped to both strengthen existing relationships with active patients and to reengage patients who were not regularly keeping their clinic appointments.
Lerma Community Health Center clinic visit attendance data.
Before their QI training, the teams in Carmen and Lerma had the will to improve care and great ideas about how to help their patients. Their rapid success, however, helps demonstrate the power of using the tools of improvement to organize their resolve and creativity to accelerate and sustain change. Taking part in the ISIA course with other teams in the region gave them the tools to develop more change ideas and to translate them into action using the Model for Improvement coupled with innovation and education. As they saw their progress, they became more convinced that the science of improvement has a huge role in helping systems improve clinical outcomes and provide better care for patients.
Santiago Nariño is an IHI project coordinator.