If Your Mom had Diabetes Wouldn’t You Want Someone Reflecting on and Improving her Care?

One of the most enjoyable parts of my job is meeting with teams who are improving patient care. Last week I visited our patient-centered medical home (PCMH) at Hunt Manor. Drs. Robin Motter-Mast and Joe Connelly led a meeting focusing on improving the team’s diabetes composite score.  Also participating were Diana Mantell, the Administrator for Population Health of the Greater Baltimore Health Alliance (GBHA), Yvonne Latchaw, RN, the care manager at Hunt Manor, and Amanda Harris, one of the team’s medical assistants. The diabetes composite measure is made up of a number of evidence-based elements in the care of diabetes. The diabetes composite score is the first measure of population health on our system-wide scorecard.

The Hunt Manor team explained to me that it is not easy to get this diabetes composite score right. Either all of the elements are present for an individual patient or it is considered a miss. The five things that they must be achieved are:

•    blood pressure needs to be less than 140/90measured in the normal range
•    LDL cholesterol less than 100 in range
•    Hemoglobin A1c level less than 8
•    daily aspirin or anti-platelet medication in patients with diabetes and ischemic vascular
     disease (IVD)
•    and non-tobacco use 

Dr. Motter-Mast explained to me that the team has worked on engaging patients 18-75 years of age with diabetes that were missing lab values. Some of these patients were also seeing endocrinologists, so the Hunt Manor team worked with those offices to gather the values.  Other patients had not been seen recently so members of the team began contacting those patients to schedule visits.  The team also reviewed their Diabetes Disease Registry to find the patients who needed to be on aspirin, and contacted them to start if appropriate.

The GBMC data warehouse, built a few years ago, now gives us the ability to create reports like the Diabetes Disease Registry. These reports show performance at the level of the system, the practice and the individual provider and are used to find the patients who are deficient on one or more measures. PCMH teams then decide which metric to work on based upon the scores for their practice.

Most primary care offices in our country don’t have such reports and are not holding themselves accountable for helping the patient achieve measurable improvement with their chronic diseases. The GBHA, with the Hunt Manor office as an example, practices advanced primary care and is holding itself accountable for maximizing the health of each patient it serves. I am very proud of them and grateful for all of their hard work.

While at Hunt Manor the rate of success on individual metrics within the diabetes composite varies from 44 percent (LDL cholesterol) to 87 percent (aspirin use in IVD and non-use of tobacco), the overall rate of patients with all five measures met is currently 20.58 percent compared to 15.9 percent in late August of this year. Although it will be very difficult to get to 100 percent, the Hunt Manor team won’t quit until they get there!


Linda A. Walsh, MD, a GBHA board member and family physician at Jarrettsville Family Care, was recently awarded the 2014 Humanitarian Award by the American Academy of Family Physicians (AAFP) at its annual meeting. The Humanitarian Award honors extraordinary and enduring humanitarian efforts by AAFP members, both within and beyond the borders of the United States.  As the medical director and chair of the Steering Committee for the Dominican Republic Medical Mission, Dr. Walsh has led annual medical missions to the Dominican Republic since 2003. Over the years, she has been instrumental in addressing the immense medical needs of the community and its lack of access to basic health care. In 2014, Walsh’s team held 13 clinics, treated more than 700 patients and initiated and oversaw the installation of a water purification system in Esperanza, a Haitian refugee village. Please join me in congratulating Dr. Walsh on her recent achievement and for her efforts to help the people of the Dominican Republic.

In my previous blog, I congratulated our Chairman of Radiation Oncology, Dr. Robert K. Brookland, for winning the Martin D. Abeloff Award for Excellence in Public Health
and Cancer Control.  This week I want to applaud him and his department for being awarded a three-year term of re-accreditation in radiation oncology as the result of a recent review by the American College of Radiology (ACR).  Re-accreditation is given to health facilities that meet specific ACR-developed practice guidelines and technical standards, following a stringent peer-review evaluation by board-certified radiation oncologists and medical physicists who are experts in the field.  This designation is an honor and reflects GBMC’s ongoing commitment to excellence in cancer care. 

Finally, I want to wish everyone in our GBMC family a Happy Thanksgiving.   I have much to be thankful for.