Toolkit for Implementing the Chronic Care Model in an Academic Environment
The D.O.I.T. Protocol
The Diabetes Outpatient Intensification Treatment (D.O.I.T.) is an easy-to-use diabetes management algorithm to immediately reduce extremely high HbA1c levels in diabetes patients.
The D.O.I.T. Protocol
The (DOIT) intervention is designed to reduce dangerously high HbA1c rates to a manageable level. Once this objective is achieved, the team continues working with the patient to achieve the Chronic Care Model target.
This cost-effective process, which saves both the pharmacist and doctor time, has two main components:
- The pharmacist receives a list for all patients coming to the clinic for the day.
- The resident reorders medications directly from this list from the pharmacy.
The DOIT protocol is essentially a safety net that is available for use at the physician's discretion. After developing the DOIT protocol, the Christ Hospital team provided daily and weekly feedback as it was used, resulting in numerous revisions over a period of months.
The Christ Hospital team developed a visual diabetes management algorithm designed to immediately treat extremely high HbA1c levels in diabetes patients. To accomplish this goal, the team designed an algorithm that was concise and easy-to-use and would effectively lower HbA1c values to more manageable levels.
The DOIT protocol was created to overcome specific barriers the team identified as thwarting attempts to lower HbA1c levels, such as:
- Patients did few or no home blood glucose tests and then "forgot" to bring them to the doctor visit.
- Patient time and transportation issues limited face-to-face interactions.
- Physician schedules limited opportunities for changing patient medication regimens.
- Physician discomfort with lack of data and waiting for the next HbA1c to make a change resulted in long delays.
An Easy-to-Use Algorithm
Although the team found many diabetes management care algorithms during a literature review, most were not user friendly. Consequently, the team physician and pharmacist developed the DOIT protocol to be an easy-to-use tool in which:
- Medication changes are based on a minimum of four home glucose readings from a fasting patient.
- Phone or face-to-face visits with nurses are used.
- One formulary medication from each of four categories (metformin, sulfonylurea, glitazone, insulin) is selected based on doctor of pharmacy's literature review.
About 90 percent of patients can get a prescription at The Christ Hospital. If started on another medicine as an inpatient and filled there, the team is able to intervene. The protocol ends at 150 mg/dL to prevent the potential for hypoglycemia.
Outcomes of the DOIT Protocol included:
- Two of eight patients were only called once, and the protocol ended because they were within range and no adjustment was needed.
- One of the eight patients had a nurse visit, followup call, and physician visit and was within range; the protocol was ended.
- Five of eight charts are still in protocol with follow-up calls scheduled.
- Nurses made notes in all eight charts. The notes were either cosigned or sent for a physician's signature.
- Voice mails from the nurses regarding a visit to the physician were documented in all eight charts.
The team used lean principles to identify work that could be reallocated or eliminated to find time for nurses to do this work. This process gave nonprovider staff autonomy to effectively overcome clinical inertia. Patients whose key indicators (HbA1c, low-density lipoprotein, or blood pressure ) were outside the ranges being examined were also placed on the protocol.