822 The Journal for Nurse Practitioners - JNP Volume 8, Issue 10, November/December 2012

Diabetes affects 25.8 million Americans andcosts $116 billion per year in direct medicaland treatment costs.1 Comprehensive control

of blood sugar, blood pressure, and lipids can lower therate of macrovascular and microvascular complicationsand mortality;2-4 however, nationally, only a third of per-sons with diabetes are under control with each risk fac-tor.5,6 Understanding the barriers that prevent primarycare providers (PCPs) and patients from reaching diabetictreatment goals is crucial. The purpose of this article is toseek answers through the existing literature for the fol-lowing questions: what are the system barriers to diabetesmanagement in primary care, and what solutions havebeen identified to overcome the system barriers? Therole of nurse practitioners (NPs) in addressing these sys-tem barriers is also discussed.

LITERATURE REVIEWA search of PubMed and CINAHL using the key-words diabetes management, system barriers, chronic diseasemanagement, and primary care was conducted. Referencelists of relevant studies were also manually searched.More than 100 articles published in English from 1990to 2011 were identified. Only those articles specificallyfocused on system barriers for diabetes management inprimary care settings were included. A total of 31 arti-cles were analyzed.

SYSTEM BARRIERS TO DIABETES MANAGEMENTA recent systematic review conducted by Nam and col-leagues7,8 summarizes that patients factors, such asadherence, beliefs, attitudes, knowledge, ethnic-ity/culture, language ability, financial resources, comor-

System BarriersAssociated With

Diabetes Managementin Primary Care

ABSTRACTA review of the literature identifies system barriers that prevent primary care providersfrom efficiently and effectively managing their patients with diabetes. For optimal dia-betes outcomes, system barriers must be addressed, and multi-stakeholder collaboration isneeded. With passage of the Patient Protection and Affordable Care Act, new incentivesexist to examine the applicability of the chronic care and patient-centered medical homemodels. Nurse practitioners need to be included to provide leadership in the redesign ofthe primary care delivery system in the care of chronic diseases like diabetes.

Keywords: chronic care model, diabetes management, nurse practitioner, patient-centered medical home, primary care, system barriers© 2012 American College of Nurse Practitioners

Jian Q. Zhang, FNP-BC, MSN, Karen A Van Leuven, PhD, FNP, and Susan Holli Neidlinger, RN, PhD

www.npjournal.org The Journal for Nurse Practitioners - JNP 823

bidities, and social support, may contribute to type 2diabetes management. Physician factors, includingbeliefs, attitudes, knowledge, patient-provider interac-tion, and communication, can also impact diabetesmanagement outcomes. In addition to the patient andphysician factors, there is increasing recognition that thecurrent health care delivery system is not designed forthe care of chronic diseases like diabetes, which requireaccessible, comprehensive, longitudinal, and coordinatedcare to reach the treatment goals.9

PCPs manage the care of over 75% of individualswith type 2 diabetes, but only a third of these patientsfollow the PCPs’ instructioncorrectly.10 In the currenthealth care system, most PCPsare stressed, some are exhaustedphysically and emotionally, andalmost all are overwhelmedwith crammed schedules, inef-ficient work environments, andunrewarding administrativepaperwork.11

Wens and colleagues,8 in a qualitative study explor-ing the thoughts and feelings of general practitionerson barriers to diabetic patient compliance, found thatthe current fee-for-service model and poor coopera-tion among providers affects diabetes care. The PCPssaid that when they referred diabetic patients to spe-cialists, the specialists took over their patients, andthey never returned to the PCPs. This failure to col-laborate may prevent PCPs from referring patients tospecialists in the future.

Wen et al8 also noted that PCPs feel that they haveless power compared to specialists because insulin-requiring diabetics are usually taken care of by special-ists. Once at this level, these patients have the right tofree dietary advice, diabetes education, and free mate-rials for self-monitoring, whereas diabetic patientswho do not require insulin are usually treated by PCPsbut have no free access to education or glucose self-monitoring equipment.8 Unfortunately, an associationis often made that specialists provide more compre-hensive care because of these additional services,whereas these services became available as a result ofdisease progression.

In a qualitative study of 25 physicians interested in pri-mary care management of diabetes in Delaware, Elliott and

associates13 identified 6 system barriers to primary care dia-betes management in small office settings as listed below:

1. A persistent orientation toward sick visits ratherthan a focus on prevention or management ofasymptomatic disease. Physicians surveyed indicatedthat the current reimbursement structure reinforcesthe value of face-to-face sick visits as opposed tocomprehensive chronic disease management. Thispersistent focus on sick visits is associated withpoor chronic diabetes care.

2. An inability to provide systematic, proactive, popu-lation-based patient management. Most physicians

surveyed desired to managepatients proactively but did nothave the capability to do so.Some physicians with paper-based charts couldn’t generate asimple registry. Physicians withelectronic health records(EHRs) believed strongly thatadditional staff were needed toproactively identify, contact, and

track patients with unmet medical needs. 3. An inability to provide adequate self-management

education (SME). Most physicians surveyed recog-nized the critical need for SME but encounteredthe following barriers: inadequate SME coverageby payers, lack of staff to coordinate the services asa result of the unpredictably variable SME coverageby payers, and limited knowledge of local SMEproviders. These barriers delay initiation and modi-fication of medical treatment.

4. Poor integration of payer-driven disease managementactivities. Physicians surveyed thought there was a lackof coordination between payer and physician effortsto manage diabetes. Some physicians appreciate payer-generated patient lists and report cards; others com-mented that additional staff were needed toincorporate the reports into their office workflow andperceived them as antagonistic. In addition, somephysicians surveyed suggested that the current payerefforts, such as telephonic disease management, areineffective and potentially counterproductive.

5. Lack of universally available clinical information.Inability to access information from specialist con-sultations, as well as laboratory and diagnostic test-ing results completed at another physician’s office

A failure to collaboratemay prevent PCPs from

referring patients tospecialists in the future.

824 The Journal for Nurse Practitioners - JNP Volume 8, Issue 10, November/December 2012

or in a different system, were found to thwart dis-ease-management efforts.

6. Lack of public health support. Physicians reported alack of support from public health and educationalsectors for diabetes teaching. Additionally, lack of acomprehensive strategy to address the public edu-cation regarding diabetes placed additional burdenon PCPs.

In summary, the structure of the current primary caredelivery system, including reimbursement methods, is notsuitable for the care of chronic diseases like diabetes.13

SOLUTIONS TO OVERCOME SYSTEM BARRIERS INPRIMARY CAREIt is essential to overcome the care delivery system barri-ers so that PCPs and patients with diabetes can achieveevidence-based goals of diabetes management. TheChronic Care Model (CCM) and Patient-CenteredMedical Home (PCMH) provide conceptual models forthe transformation of primary care. Elliott et al13 indi-cated that the significant systemic barriers experiencedby PCPs practicing in small offices affect most of theCCM domains. These barriers served as a basis for devel-opment of the CCM to transform the current reactivehealth care system to one that is proactive and focusedon preventive care and chronic disease management.14,15

The CCM was developedby Wagner in 2001 as a guidefor chronic illness manage-ment within primary care.16

The model summarizes thebasic elements for improvingcare in health systems at thecommunity, organization,practice, and patient levels. Itconsists of 6 pillars:

1. Health care organization,which creates a culture, organization, and mecha-nisms that promote safe high quality care;

2. Delivery system design, which ensures efficient,effective clinical care and self-management support;

3. Decision support, which promotes clinical care thatis consistent with scientific evidence and patientpreferences;

4. Clinical information systems that facilitate access topatient and population data, thereby improvingefficiency and effectiveness of care;

5. Community policies to mobilize resources to meetpatients’ needs;

6. Self-management support, which empowerspatients with chronic disease to manage theirhealth and health care.

Through a systematic review, Bodenheimer and col-leagues17 identified that 32 of 39 studies of diabetes careprograms featured elements of the CCM and reportedthat interventions based on these components improvedat least 1 process or outcome measure for diabeticpatients. Bodenheimer and colleagues17 further reviewed27 studies regarding CCM interventions and costs andreported that 18 of 27 studies demonstrated reducedhealth care costs or lower use of health care services.

Strickland et al18 surveyed 25 primary care practicesto examine whether offices that incorporated more fea-tures of the CCM delivered better diabetes care andmore counseling for diet or weight loss and physicalactivity in community-based primary care settings andfound that higher levels of CCM implementation wereassociated with better diabetes assessment and treatmentof patients in the community primary care setting.

After implementing a diabetes management programbased on the CCM model, Yu and Beresford19 reportedsignificant improvement in the process measures, eye andfoot exams from 19% and 30.5% before intervention to

38.1% and 51.4% after interven-tion, respectively. The metabolicmeasures of glycolated hemo-globin (HbA1c), blood pressure,and low density lipid (LDL)goals went from 5.7% beforeintervention to 17.1% afterintervention.

Using the CCM as a guide,Boville et al20 incorporatedNPs into the care model for

patients with diabetes in a hospital-based clinic setting.Through use of planned visits, a patient registry, medica-tion protocols, and collaboration with other health caredisciplines, the clinical outcomes were improved inglycemic and blood pressure control and lipid manage-ment in the pilot sample of 11 adult patients with dia-betes.

The PCMH is another innovative delivery modelthat may improve diabetes care. The Patient Protectionand Affordable Care Act (PPACA) authorizes commu-

It is essential to overcomecare delivery system

barriers so that PCPs andpatients can achieve

evidence-based goals.

www.npjournal.org The Journal for Nurse Practitioners - JNP 825

nity-based interdisciplinary, interprofessional teams tosupport PCPs in creating medical homes. The model isexpected to strengthen the infrastructure of primary care.The basic elements of a PCMH are care coordination,quality and safety, whole person orientation, personalphysician, physician leadership, enhanced access, and pay-ment. Each element is further described in Table 1.21

Multiple nursing organizations, including theAmerican Academy of Nurse Practitioners, the AmericanCollege of Nurse Practitioners, and the AmericanNurses’ Association, have worked hard to include NPsand other nonphysicians in the extension of the PCMHdemonstrations.22 In a published policy monograph in2009, the American College of Physicians (ACP)endorsed the inclusion of NP-led practices to testPCMH models within the medical home demonstrationprojects and emphasized the importance that both physi-cian and NP models be held to the same eligibilityrequirements and evaluation standards.23

Bojadzieski and Gabbay24 reviewed 8 PCMH demon-stration projects reporting outcomes in diabetes care. Theyfound that all 8 demonstrations showed improved out-comes as measured by HbA1c, blood pressure, and LDLcholesterol; a decreased use of inpatient and emergencycare by diabetic patients; and reduced cost in some meas-

ures. All 8 projects included care coordination as their keytransformation, although differing from each other in theiremphasis on other medical home elements.

Most of the PCMH demonstration projects adopted the3-part payment model espoused by the Patient-CenteredPrimary Care Collaborative (PCPCC), which includedongoing fee-for-service payments, a fixed (usually monthly)case management fee, and potential for additional bonusesbased on clinical performance.25 Use of this payment modelencourages team efforts to improve clinical outcomes,incentivizes PCPs to refer diabetic patients to other availableresources to learn self-management skills, and supports costreduction related to complication management.26

DISCUSSIONPCPs focus on episodic care because the current paymentstructure penalizes them for spending more time to man-age chronic diseases like diabetes and may prevent themfrom referring to specialists or diabetes self-managementprograms because of potential loss of patients.8,12 PCPssurveyed voiced concern about lack of resources to proac-tively manage their patients with diabetes and a lack ofsupport from payers. Some providers even perceive thatthe payer-driven disease-management activities are ineffi-cient, ineffective, and potentially counterproductive.13 It is

Table 1. Basic Components of Patient-Centered Medical Homes

Coordination and integration of care Exchange of health-related information through electronic health records; use of patient registries; care coordinator services; the physician arranges care with subspecialists and consultants, guides the patient through the health system

Quality and safety Decision support based on updated practice guidelines, eg, incorporation of most current care guidelines in daily patient flow, use of checklists and worksheets to guarantee consistency; use of patient registries to review performance data

Whole person orientation Comprehensive care, including preventive and end-of-life care

Personal physician Each patient has a personal physician who is a first contact for all new health issues; the physician knows the important psychosocial factors that may influence the health of the patient, is culturally competent, and offers long-term comprehensive care.

Physician-directed medical practice The physician oversees the health care team whose members communicate closely and is a key link in coordinating their work for the optimal benefit of the individual patient.

Enhanced access Flexible scheduling system; easy access to members of the health care team

Payment Quality-based payment in addition to fee-for-service reimbursements of face-to-face visits; reimbursement for care coordination; recognition of complexity and severity of illness; sharing of savings achieved from reduced health care costs

826 The Journal for Nurse Practitioners - JNP Volume 8, Issue 10, November/December 2012

important for payers to consider incorporating PCPs’input when developing a disease management programand reimbursement structure.

Care coordination, the first principle of PCMH, isanother important aspect of medical care that links all thepatient care activities provided by 2 or more participantsinvolved in a patient’s care to facilitate the appropriatedelivery of health care.27 PCPs surveyed report that it isextremely difficult to coordinate care for patients withdiabetes, even in primary care practices with EHR sys-tems. While EHR systems can generate a diabetes reg-istry, added staff time and effort are required to contactpatients or other providers.13

Care coordination is generally not reimbursable, andmost primary care practices do not have the dedicatedpersonnel to coordinate care effectively.13 The goals ofcare coordination are to make high-quality referrals andtransitions that meet the 6 Institute of Medicine “QualityChasm” aims for high-quality health care and to ensurethat all involved providers, institutions, and patients havethe information and resources needed to optimize thecare of patients. The high-quality referral and transitionshould be timely, safe, effective, efficient, patient-centeredand equitable.28

Payment reform is the key to the successful imple-mentation of the PCMH model because the currentpayment model is focused on face-to-face visits.24

Time for care coordination must be recognized. A 3-part management fee and performance bonus, as rec-ommended by PCPCC, offers incentives to PCPs tocoordinate diabetic populations, and individualpatients’ complex care needs to optimize and achievebetter overall outcomes. PCPs with insufficient per-sonnel to coordinate care could partner with payersfor care coordination focused on evidence-based dia-betes management guidelines.

PRACTICE IMPLICATIONS The current primary care model is not structured forchronic diseases. In order to reach optimal diabetes man-agement, the identified system barriers must be overcome,multistakeholder collaboration needs to be developed, andthe primary care delivery system has to be redesigned usingCCM and PCMH models. The reimbursement systemshould be changed to reflect the quality of preventive care.Care coordination must be included in the new care deliv-ery system. NPs are ideally suited to serve as leading PCPs

for diabetes care because NPs provide high quality of carein a cost-efficient way,30,31 NPs have traditionally taken anactive role in chronic disease management because of theirability to treat patients holistically,29 and there is a limitedsupply of PCPs.17 Remodeling health care by introducingCCM concepts or adopting the PCMH model is bestaccomplished by extensive use of NPs. In this revised sys-tem, NPs may serve as PCPs, disease management coordi-nators, and team members.

References

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2. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of amultifactorial intervention on mortality in type 2 diabetes. New Engl J Med.2008;358(6):580-591.

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9. Grumbach K, Bodenheimer T. A primary care home for Americans. JAMA.2002;288(7):889-893.

10. Shumaker S, Schron E, Ockene J, McBee W. The handbook of healthbehavior change. New York: Springer; 2004.

11. Sommers LS, Hacker TW, Schneider DM, Pugno PA, Garrett JB. Adescriptive study of managed-care hassles in 26 practices. West J Med.2001;174(3):175-179.

12. Alberti H, Boudriga N, Nabli M. Primary care management of diabetes in alow/middle income country: a multi-method, qualitative study of barriersand facilitators to care. BMC Fam Pract. 2007;8(1):63.

13. Elliott DJ, Robinson EJ, Sanford M, Herrman JW, Riesenberg LA. Systemicbarriers to diabetes management in primary care: a qualitative analysis ofDelaware physicians. Am J Med Qual. 2011;26(4):284-290.

14. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness.Managed Care Q. 1996;4(2):12-25.

15. Wagner EH, Austin BT, Von Korff M. Organizing care for patients withchronic illness. Milbank Q. 1996;74(4):511-544.

16. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care:translating evidence into action. Health Aff. 2001;20(6):64-78.

17. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care forpatients with chronic illness. JAMA. 2002;288(14):1775-1779.

18. Strickland PAO, Hudson SV, Piasecki A, et al. Features of the Chronic CareModel (CCM) associated with behavioral counseling and diabetes care incommunity primary care. J Am Board Fam Med. 2010;23(3):295-305.

19. Yu GC, Beresford R. Implementation of a chronic illness model for diabetescare in a family medicine residency program. J Gen Intern Med.2010;25:615-619.

20. Boville D, Saran M, Salem JK, et al. An innovative role for nursepractitioners in managing chronic disease. Nurs Econ. 2007;25(6):359-364.

21. American Academy of Family Physicians, American College of Physicians,American Osteopathic Association. Joint priniples of the patient-centeredmedical home. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. 2007. Accessed September 6, 2012.

22. Edmunds MW. Fulfilling the vision of NP leadership to help protect NPpractice. J Nurs Pract. 2008;4(9):642.

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23. American College of Physicians. Nurse practitioners in primary care. 2009.http://www.acponline.org/advocacy/where_we_stand/policy/np_pc.pdf.Accessed September 6, 2012.

24. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes.Diabetes Care. 2011;34(4):1047-1053.

25. Bitton A, Martin C, Landon BE. A nationwide survey of patient centeredmedical home demonstration projects. J Gen Intern Med. 2010;25(6):584-592.

26. Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: final economic andclinical results. J Am Pharm Assoc. 2009;49(3):383-391.

27. McDonald K, Sundaram V, Bravata D, et al. Closing the Quality Gap: ACritical Analysis of Quality Improvement Strategies. Vol. 7: CareCoordination. Rockville, MD: Agency for Healthcare Research and Quality;2007.

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30. Gambino KK, Planavsky L, Gaudette H. Transition toward a nursepractitioner-managed clinic. J Cardiovasc Nurs. 2009;24(2):132-139.

31. Wright W, Romboli J, Ditulio M, Wogen J, Belletti D. Hypertension treatmentand control within an independent nurse practitioner setting. Am J ManagCare. 2011;17(1):58-65.

Jian Q. Zhang, DNP(c), FNP-BC, MSN, is the chief outpatientservices & innovation officer for a Chinese hospital in SanFrancisco and an assistant clinical professor at the University ofCalifornia–San Francisco. She can be reached atJianz@chasf.org. Karen A Van Leuven, PhD, FNP, is an asso-ciate professor at the University of San Francisco. Susan HolliNeidlinger, RN, PhD, is president of Evaluation & Design:Health and Human Services in Littleriver, CA. In compliancewith national ethical guidelines, the authors report no relationshipswith business or industry that would pose a conflict of interest.

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