Home Visits for Diabetes: A Model for Improved Chronic Care

By: Edward Ratner, MD

Diabetes is a relatively common, chronic disease primarily managed by primary care providers in the outpatient (clinic) setting. So why should it be a topic for an organization dedicated to home based medical care? I answer that by examining where diabetes is really managed and who is doing the management.

Diabetes is the epitome of a self-managed disease. Within hours or at most days of diagnosis, patients typically must begin to measure their blood sugars, document results of these measurements, self-medicate with one or more new medications, alter their diet, begin an exercise program, and start watching for symptoms of hypo-or hypoglycemia. It is so complex for the patient that Medicare has authorized specific payment for educators to teach patients with diabetes to self-manage. The location of all of that self-management is not the clinic or the diabetes educator's classroom – it is the home.

We propose that primary care providers should be able to identify and address the barriers to good self-management of diabetes. Moreover, the best way to accomplish that task is to visit the patient, at least once, in the home.

A key barrier to ideal self-management of a chronic, mostly asymptomatic disease like diabetes is lack of belief in the medical advice given. It can be challenging for a patient to accept that is worthwhile to make significant lifestyle changes, to draw blood one or more times per day and to start new medications all for the sake of correcting an abnormality on a blood test, to prevent complications 20 or more years in the future.

One of the best ways for a primary care provider to demonstrate commitment to working with a patient to manage a serious chronic problem is to make a home visit. Sitting at the dining room table with the patient and family members, frank and open discussion of diabetes and its current and future impact on the whole family can take place. The primary care provider can build invaluable trust and rapport in such a visit. That relationship building will help everyone as the inevitable challenges in management of diabetes arise over the long term. The opportunity for such a rapport-building visit is just as important for the long-standing diabetic or long-standing office-based relationship. I would encourage everyone reading this column to simply pick a patient with new or difficult to manage diabetes and schedule a home visit in the next month. I predict that you will see a change in your relationship with that patient and will see improved attention by the patient to the self-management plan.

Besides talking with the patient and family, what else should the primary care provider do during the home visit? There are a number of home based assessments that are critical to understanding a patient's disease and helping create or improve an individualized care plan. There is no better place to do a medication review than in the home. Duplicate medications, medications not taken as prescribed, and over the counter medications are easily recognized. The food in the fridge and cupboards is a good proxy for the food being eaten. Finally, care and cleanliness of the home and yard may provide insight into ability or willingness to care for oneself and self-manage the diabetes.

In summary, diabetes, a chronic, self-managed disease, is by definition a home-based condition. A home visit by the primary care provider is a tool to improve the relationship between the provider and the patient, which may improve adherence to care plans. The home visit can also provide valuable information to the primary care provider about the setting in which self-management is occurring. A home visit should be considered for all patients with a new diagnosis of diabetes or with office-based evidence of problems with self-management.