Nexus Innovation Network

Member since: January 2016

Intervention: Interprofessional Care Coordination Teams to Address Diabetes

Partners: 

• Loyola University Chicago Institute for Transformative Interprofessional Education

• Loyola University Chicago Marcella Niehoff School of Nursing

• Loyola University Chicago Stritch School of Medicine

• Loyola University Chicago Medical Center

Occupations represented: Students and professionals including care coordinators, dieticians, nurse practitioners, nurse managers, physicians, psychologists, and social workers.

Overview: Loyola University received HRSA funds to develop nurse-led interprofessional teams in a family medicine clinic.  This participatory action project involved all members of the clinic in the creation of a redesigned model of care delivery to improve patient outcomes for a moderate-high risk population of individuals with diabetes using the Patient-Centered Medical Home (PCMH) model of care delivery.

This project studies the impact of a nurse led; Interprofessional care coordination team on both outcomes for diabetic adult patients and outcomes for health care providers. Each of the three care teams is coordinated by a registered nurse and includes a nurse practitioner, physician, social worker, and a dietician. When available, students of these professional roles also participate. Care teams will meet monthly as well as just prior to a patient’s visit. The pre-visit huddle clarifies plans for the day and ensures the care team has up to date information. Individual members of the care team may visit the patient at home. All members of the care team receive standardized instructions for their role within the team through video modules created at Loyola specifically for this project.

Patient outcome measures for this project include HgA1c levels, BMI, and rates of completed annual foot and eye exams. Patient engagement and satisfaction scores, provider satisfaction scores and costs of care will also be measured.

Intervention study question:

• What is the effect of health care delivered by an interprofessional care coordination team among adult diabetic patients.