Most recent estimates by the California Diabetes Program were that 42,265 residents of San Francisco have diabetes.
Over 20% of those patients (8,700) are in the San Francisco Department of Public Health diabetes registry receiving primary care in DPH clinics. There are several thousand other patients receiving primary care in the consortium of safety net clinics that are not part of the DPH and still more patients with diabetes in the city that are not receiving usual care who arrive in our urgent care and emergency department. Thus, the SFGH Diabetes clinic is the referral center for as many as 25% or more of the city’s patients with diabetes. We obviously don’t have the capacity to see every patient with diabetes and nor would that be appropriate. Thus the focus of diabetes care within the division has broadened over the last five years from a sole focus on individual visits to include a strong emphasis on support for primary care providers, who are providing the majority of diabetes care in the patients’ medical homes.
Guiding Goals and Principles
Multi-disciplinary care focused on barriers to self-management, nutrition, and mental health issues Support primary care diabetes management through guidelines, education and novel patient education tools Get patients to goal quickly Target early insulin use overcoming patient and provider barriers Increase access to intensive diabetes management Develop cost effective strategies
In 2008, via Healthy San Francisco funding, there was a significant expansion of the diabetes program. Three part-time NPs with diabetes expertise (1.5 FTE total) were hired and The Diabetes Center for High Risk Populations was launched. Our weekly diabetes clinic is multidisciplinary with MDs, NPs, a diabetes educator, a nutritionist and a mental health worker available to see patients. In addition we’ve added an NP clinic focused on intensive insulin management and have explored alternative care options including Spanish group medical visits at the Family Health Center, Cantonese group medical visits at Ocean Park Health Center, post gestational diabetes postpartum group medical visits, a monthly half day diabetes clinic at the jail, and monthly insulin start groups in English and Spanish to overcome patient fears around insulin. Unfortunately data on our NP and group visits are not easily obtained due to the use of different visit coding. Data for nine months in 2010 that includes the majority of NP visits shows they have added more than 1000 visits a year, more than doubling our diabetes visit volume since 2006.
The diabetes team has staffed diabetes education days and screening days in conjunction with primary care clinics, churches and department of public health initiatives throughout the city. In addition we’ve visited over 15 Department of Public Health clinics and independent safety net clinics to do provider trainings and education. In 2011 we obtained funding to conduct a free, daylong CME event for safety net clinics (discussed in more detail under education).
Examples of Guidelines and Tools Generated
With a new emphasis an assisting primary care providers, the Diabetes Team has developed resources to help standardize care and help patients get to goal more quickly.
- Oral medication guideline pocket card, focused on rapid medication titration allowing for more uniform care among providers
- Standardized RN protocol allowing an RN to do oral medication titration based on the guideline without the need for a PCP visit
- Low literacy insulin teaching flip chart focused on addressing patient fears around insulin (possible by funding from the SFGH Foundation)
- Bimonthly electronic diabetes newsletter for PCPs in the safety net providing updates on formulary changes, summary of new studies, updates from the American Diabetes Association
- Web based resources on the intranet