SHM Converge Scientific Abstract ePoster Gallery-Maximizing Quality While Reducing Quantity: An Approach to Complex Care in Patients With Type 1 Diabetes Mellitus

Pdf Summary

This poster describes the University of Virginia’s HOME Program approach to complex care for a small cohort of highly hospitalized patients with type 1 diabetes mellitus. The program enrolls patients with frequent admissions and creates individualized care plans (ICPs) through chart review, collaboration with primary care and endocrinology teams, and patient interviews. These plans are stored in the electronic medical record and provide detailed medical history, guidance for common acute presentations, and discharge/follow-up recommendations. A nurse coordinator, social worker, and hospitalists support longitudinal care coordination.<br /><br />The authors hypothesized that streamlined diabetes management plus dedicated care coordination would improve outcomes, not only by reducing utilization but also by lowering adverse inpatient events such as diabetic ketoacidosis (DKA), hypoglycemia, hyperglycemia, and ICU use. Six patients with type 1 diabetes and more than four hospitalizations in the prior year were enrolled between January and December 2019, and outcomes were tracked for 24 months before and after enrollment.<br /><br />Results showed reductions in both emergency department visits and hospitalizations after enrollment. The proportion of admissions involving ICU care fell from 15.9% to 7.9%. Hypoglycemic events with glucose below 54 mg/dL decreased from 3.3% to 1.5%, while mild hypoglycemia slightly increased. DKA events decreased from 29.8% to 20.5%, and hyperglycemic events remained unchanged. Endocrinology consultation use increased substantially, from 4% to 64.4%.<br /><br />The authors conclude that individualized care plans and care coordination may improve both utilization and patient-centered quality outcomes in medically and socially complex patients with type 1 diabetes. Future plans include expanding the cohort, tracking quality-of-life measures, incorporating broader hospitalization data, and extending tailored outpatient or virtual primary care support.

Asset Subtitle

Ian Crane

Meta Tag

Author List Amber Inofuentes, Guy Lushin, Ian Crane, Jason Adams, Teresa Radford

Category Innovations

Concept Individualized Care Plan

Concept Care Coordination

Concept Type 1 Diabetes Mellitus

Concept Health Care Utilization

Concept Diabetic Ketoacidosis

Distinguished Non-Finalist

Presenter Organization University of Virginia Health System

Presenting Author Ian Crane

Track Quality Improvement

Keywords

type 1 diabetes

complex care

individualized care plans

care coordination

hospitalization reduction

diabetic ketoacidosis

hypoglycemia

emergency department visits

endocrinology consultation

University of Virginia HOME Program

Individualized Care Plan

Care Coordination

Type 1 Diabetes Mellitus

Health Care Utilization

Diabetic Ketoacidosis