Why It Matters
The third week of my Las Vegas rotation has quickly crept up on me, and we are in the throes of rolling out my population health project. For my month here, I have decided to focus on diabetes.
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Dispatches from Las Vegas: Improving Diabetes Management

By IHI Open School | Wednesday, February 11, 2015

Diabetes management

For four weeks, Eva Luo, an Open School student and an MD/MBA candidate at the University of Michigan Medical School and Harvard Business School, is doing a rotation at Iora Health clinic that serves workers in the culinary union in Las Vegas to learn about their model of primary care. While there, she’s also going to be working on a population health project through the Open School’s new initiative, the Improvement Change Agent Network, or I-CAN. Below is her fourth dispatch for our blog (read the first here). Look for more of her posts on our blog, and contact us at openschool@ihi.org if you want to write your own post.

The third week of my Las Vegas rotation has quickly crept up on me, and we are in the throes of rolling out my population health project. For my month here, I have decided to focus on diabetes. I’m hoping to empower the health coaches at Culinary Extra Clinic to better support their patients who need the extra help.

Our quantitative goal is to help at least 70 percent of all our diabetic patients to have a Hemoglobin A1c of less than 8 percent for at least twelve months. (This signifies that their diabetes is well-controlled.) Our more qualitative goals are to:

  • Develop an easy-to-follow, structured program that health coaches can implement with each of their patients.
  • Provide enough flexibility within the program to allow health coaches to assert their own ingenuity and creativity in serving their patients.
  • Create standardized resources and share best practices among all health coaches at Culinary Extra Clinic.

In my second week here, I tried to better identify some of the challenges we were having with diabetes management. Two medical residents who preceded me in improving diabetes care here had completed individual chart reviews, analyzed diabetic population data to determine health coach and practice-wide trends, and interviewed health coaches and clinicians. I pored over the results of their work and identified a few areas for improvement:  

  • Proactive adjustment of patients’ insulin dosage. Unlike pills, insulin is prescribed in different amounts for each patient, depending on their individual response. Normally, patients wait for weeks between appointments to have their insulin dosage adjusted. Aggressive management allows patients to be on just the right amount of insulin much more quickly, which mitigates the risk of end organ damage due to high sugars.
  • Transitioning uncontrolled diabetics on three oral medications to insulin, which can better control their blood sugar
  • Medication adherence plans that are sensitive to difficult work schedules
  • Consistent and timely care for other diabetic concerns (i.e. foot exams, management of blood pressure and cholesterol, vaccines, etc.)
  • Patient education on diabetic diets that is culturally sensitive
  • Patient education on easy exercise and fitness strategies


We’ve also assembled an execution team and recruited some health coaches who have agreed to test our changes. My wonderful execution team includes health coach Alejandra Sandoval, Dr. Ali Khan, and operations coordinator Karina Bocker. Some of the interventions that we will be testing in the next few weeks include:

  • Creation of a diabetes-specific “worry list” — Each health coach will manage their own list of diabetic patients that are identified as having uncontrolled diabetes and are engaged with the clinic. With limited resources and so many diabetic patients, the Culinary Extra Care Clinic invests in patients who have shown interest in the clinic and in improving their health.
  • Weekly diabetes office hours: Providing health coaches with uninterrupted time each week that will be dedicated to calling patients and following up with medication and lifestyle management. Before, health coaches made these calls but didn’t have dedicated time to do it.
  • Diabetes Curriculum: Creation of standardized resources on important diabetes education topics that health coaches will walk through with each patient on a weekly basis.
  • Patient Diabetes Passport: We’re introducing this health journal to help stimulate patient engagement in the diabetes program and active management of their own diabetes. This will be a centralized resource that patients can refer to as well as record positive behaviors. Ultimately, this tool will also provide health coaches with data on areas for improvement in patient education and behavior.

We have recruited three wonderful health coaches who are brave enough to join us on this beta testing journey: Barbara, Jeannette, and Roni. We have also finalized the Diabetes Curriculum and the standardized resources for health coaches, and have developed “worry lists” of diabetes patients for each health coach. This week, we will focus our testing on the concept of the Weekly Diabetes Office Hours.

There is so much work ahead of us, but without a doubt, everyone is excited! Onwards we will continue toward diabetes control! 

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