Intensive Primary Care Diabetes Clinic

Director: Fred Alcantara, MD

The effect of diabetes mellitus on multiple organ systems has been well-documented. At the heart of minimizing/controlling the adverse sequelae of the disease is optimal glycemic control. Achieving this can be difficult for both patients and their primary care physicians, as the factors contributing to control are diverse and difficult to address in a primary care appointment with a single family physician. Contributory issues include: understanding of the disease process and the medications used to treat it, diet and lifestyle modification, financial and psychosocial support, and access to medications, testing supplies and follow-up appointments with the PCP and specialists. Deficiencies in any of these areas present a barrier to proper management of diabetes.

Patient-centered Medical Homes seek to improve the glycemic control of their patients through multiple means, one of which is the use of a team-based model of patient care. The WVU Department of Family Medicine has implemented an innovative model, which provides a suite of diverse services accessible to patients in a single outpatient visit – resulting in improvements in diabetic control and in the education of all participants, including patients.


The Intensive Diabetes Clinic (IDC) implemented in the Department of Family Medicine facility provides consultation with a “team” composed of a Certified Diabetic Educator/Dietitian, Case Manager, PharmD, nursing staff, a Family Medicine Resident, and a Board-Certified Family Medicine attending physician.

Patients are referred to the IDC by their primary care physicians based on criteria which include: newly-diagnosed diabetes, established diagnosis of diabetes with failure to achieve improvement in glycemic control despite at least six months of aggressive medical intervention, and a hemoglobin a1c of greater than or equal to 9%.

Scheduled patients are tracked using a clinic “trackboard” in order to ensure that each patient is seen by all relevant IDC team members. Upon arrival to the clinic, the nursing staff provides the patient with a questionnaire to begin the process of self-reflection/evaluation which subsequently guides and “individualizes” the course of their IDC appointment. Nursing staff also compile background information consisting of vital signs, medications taken, most recent lab results, immunization status (including pneumonia, influenza, shingles), smoking status, and the status of appointments with specialists (Ophthalmology, Podiatry, and Dentistry). If no recent Ophthalmology consult is noted, nursing staff performs retinal screening imaging using an IRIS retinal photography device. The Certified Diabetic Educator assesses the patient’s understanding of diabetes, blood glucose monitoring, and the medications used to treat the disease. A history and assessment of the patient’s nutrition, weight, and physical activity is performed. Case Management discusses issues relating to the patient’s access to health care, medications, and testing supplies – commonly with respect to finances, health insurance, transportation, and current living arrangements. The Family Medicine resident discusses barriers identified by the patient on the self-assessment questionnaire, reviews labs and fingerstick logs, adjusts medications as necessary, and performs a physical exam (including a diabetic foot exam). In addition, residents are trained to assess the patient for depression using the “SIG E CAPS” screening pneumonic. Once information has been gathered, a “team huddle” is performed in order to discuss the barriers identified by each member and a plan of action to address those barriers is formulated. This is facilitated by the attending physician. After the huddle, the resident and attending discuss the plan with the patient and field any questions that arise. Initial follow-up is scheduled for four to six weeks, with subsequent IDC or specialist follow-up as necessary. Case Management follows up with each patient between visits to address questions or new needs that may arise.

Educational Objectives

  • Define steps and the process involved in implementing a diabetes clinic (or other team-based intervention) in a residency clinic.
  • Identify methods for team organization and communication.
  • Identify learning opportunities for trainees in team-based multidisciplinary clinic.


The IDC has been in place for four years, and outcomes of this innovative approach to the management of diabetes are positive. In addition to achieving improved glycemic control for the majority of patients, the multidisciplinary team-based approach has also provided learning opportunities for all participants, including patients. Evidence for success is reflected in almost all the available patient slots being filled, even after four years of operation. Team teaching has included PharmD residents from UPMC as well as WVU medical, dietitian, and pharmacy students.

For more information, please contact Fred Alcantara, MD.