The diabetes epidemic continues unabated in this country. Over the past decade, fewer than 50% of people with the condition have met the recommended A1c goal of below 7. In fact, despite the advent of effective new medications and easier-to-use technology in the past 15 years, A1c levels have been going in the absolutely wrong direction — up, not down.

Compounding this crisis is a lack of endocrinologists to effectively serve the massive influx of patients. Even so, my endocrinology colleagues tell me they manage thousands and thousands of patients. They also say that most of the patients they see can be managed by primary care.

It’s clear that this model of care needs to evolve. At my health system, we have 60,000 people with diabetes in our Accountable Care Organization and a handful of endocrinologists — a workforce issue facing health systems across the country. So we’ve made the decision to invest in the power of collaboration, leveraging everyone’s expertise with the goal of improving outcomes for our patients with diabetes. We believe it’s a path toward addressing both the clinical and workforce challenges.

In this new model, primary care providers maintain their role as the patient’s main source of care. But they receive the expert guidance of the endocrinology team for patients who need it.

Here’s how it works: The endocrinology and advanced primary care teams work collaboratively to create a plan for how to manage the patient with diabetes, employing a checklist. In some cases, primary care physicians also receive a rapid consult to confirm the diagnosis and treatment plan. 

At the same time, the endocrinology team reviews the records of patients with uncontrolled diabetes and makes recommendations for interventions, such as changing a medication or making a referral to a nutritionist. It’s a conversation, not a directive — just a simple way of messaging. And it is only possible because we have built trust between the different care teams.

Reviews personalized to the patient generate different interventions, depending on circumstances. For example, some patients are referred to weight management clinics, others with heart disease to a cardiometabolic clinic, others to nephrology, and patients with complex diabetes to endocrinology. Rounding out the interventions are a phone call or telehealth visit with a pharmacist to cover medication issues and barriers, plus a diabetes care and education program.

The goal is to move away from care that is transactional, reactive and largely specialty-based to care that is proactive, relational and primary care-based. It’s important to preserve what each member of the care team does best. Success in this new world is measured by how well we’re managing the entire population of patients with diabetes, not just how many patients we see. 

We’re scrupulously measuring how accurately our patients with diabetes are being diagnosed,  as well as whether they’re receiving guideline-concordant therapy; controlling their disease; being diagnosed and treated for behavioral health, social needs and being referred for care; and avoiding unnecessary hospitalizations, ED visits and readmissions.

So, does it work? I’m thrilled to say it does. We piloted and published this program, and most of our patients with diabetes are now managed in advanced primary care. Moreover, 666 patients with uncontrolled diabetes in our ACO received a chart review by the endocrinology team. The review takes just 4 minutes per patient, yet it produces outsized results. After six months, every intervention we tried led to statistically significant reductions in hemoglobin A1c, with the average being 1.6.

Another important result? The program was well received and adopted by primary care. That was also a key metric. As health gatekeepers, primary care providers have a very special connection with their patients like no other. They know their patients best. Specialists can suggest to them what they feel is best, but at the end of the day, the primary care provider and the patient are the decision-makers.

As we move forward, it’s clear that challenges, like the diabetes epidemic in the U.S., requires fresh approaches. But this collaborative model that draws on the unique strengths of primary and specialty care is by no means limited to just this one condition. We’re trying similar programs at my health system with chronic kidney disease, heart failure, diabetes, COPD and hypertension. 

Well-regulated AI may also someday play a role, perhaps sooner than anyone thinks, allowing us to manage large and growing patient populations. More creative payment options from health insurers are also necessary. Value-added work devoted to designing care and managing disease on the part of specialized teams is just as important as measures of clinical productivity. Plans should reflect that.

Effective collaborations between primary and specialty care providers, with supportive care teams, will remain the cornerstone. They may be complex, but they’re the key to delivering high-quality, patient-centered care for diabetes and every other chronic condition. 

We can also never lose sight of the power of love as a driver of needed change — that energy that uplifts and connects us all and generates all that is good in healthcare. With clear goals in mind and leveraging this energy, we can move past the status quo, innovate new models, evaluate what works and transform healthcare.

Peter Pronovost, MD, PhD, FCCM, is the chief quality and clinical transformation officer at University Hospitals in Cleveland. He also holds the Veale Distinguished Chair in Leadership and Clinical Transformation.