Diabetes Care in The Netherlands: - Novo Nordisk

Integrated behavioural interventions have have been been successful in inimproving complianceExample: Diabetes Population Management Program of Kaiser Permanente (2003)Level 3Intensive Care• Complex medical issues• Psycho -social barriers toself-managementEndocrinologist / Diabetologist• Confirms diagnosis• Identifies comorbidities• Optimizes medication regimen• Mentors case and care managersCase Manager•Coaches members in crisis•Manages access to specialtyand ED care•Coordinates care across continuumLevel 2• ED visits• Hospitalization• HgA1c > 8.5%• Microalbumin > 30Any of the above WITH• HTN . DyslipidemiaCare ManagementOutreach and Triage•Prioritize CV risk factors:•HTN Dyslipidemia (LDL > 100)•Treatment according to protocols•Behavior change / motivation•Reinforce self-management•Patient returns to Level 1Week 1Intake Visit•One-to-one•Office visit•Risk reduction•Goal settingWeek 2Group Appointment•Assessment•Care Manager•Behaviorist•DietitianMonthlyGroup Appointment• Clinical / behavioralinterventions• Care Manager• Behaviorist• Dietitian2-6 MonthsTelephoneFollow-up Visits•(1:1 office visit asneeded)Level 1Self-Care• Diabetes is well controlled• Member practices effectiveself-careLiving Well with Diabetes Class• ,,, and othersAs NeededEducational Resources• Healthwise Handbook• KP onlinePrimary Care Team• Reviews, adjustmedications• Regular screening• Reinforcesself-managementSource:Kaiser permanente, Booz & Company AnalysisBooz Source: & Company Kaiser 14 November permanente, 2011Booz & Company AnalysisPrepared for Novo Nordisk4855