MON-665 - Diabetes Collaborative Care: A Multidisciplinary Approach to Diabetes Management

Introduction: Throughout the world, diabetes is a major cause of mortality and morbidity, and a leading driver of healthcare costs. Multiple studies have shown that a multidisciplinary approach to diabetes management leads to improved outcomes. The Diabetes Collaborative Care (DCC) project was developed by the UCSF Office of Population Health, School of Nursing, and the Division of Endocrinology and Metabolism at the School of Medicine. This project aims to lower A1c and improve patient engagement and self-management skills. Enrollment criteria include type 2 diabetes, A1c > 8%, a UCSF primary care provider, and enrollment in specific health plans. Care navigators reach out to prospective participants and arrange intake appointments with nurses. At weekly case conferences, nurses present new and follow up cases to an adult endocrinologist and primary care nurse practitioner, who make recommendations that the nurses convey to the participants and their primary care provider. We present three cases of patients who greatly benefited from participation in the DCC.

Case 1: A 58 year old woman began the DCC with a baseline A1c 9.6%, on glargine 23 units in the morning and 18 units in the evening, aspart 5-10 units with meals, liraglutide, and metformin. She received bilateral eye injections every 6 weeks for retinopathy. After joining the DCC, we began and up-titrated tirzepatide. After 3 months, she was off insulin. Five months after completing the DCC, A1c was 6.1 and retinopathy was not active.

Case 2: A 49 year old woman began the DCC with A1c 11%, on glargine 70 units/day, metformin, glimepiride, and empagliflozin. After enrolling, we helped her resume tirzepatide, decreased glargine to 12 units/day, stopped glimepiride, and up-titrated empagliflozin. We arranged for bubble-packed meds and assisted with two medical billing errors. After 8 months in the DCC, her A1c was 6.9.

Case 3: A 38 year old woman with an A1c 10 when she joined postpartum, on glargine 48 units/day and metformin. The DCC team advised her about glucose management options while breastfeeding; after she completed breastfeeding, she started and up-titrated tirzepatide. Two months after starting tirzepatide, she was able to stop glargine.

Conclusion: The DCC program, a nurse-led intervention, has enabled participants to improve diabetes management with significant A1c lowering, as well as improved access to newer medications and technology.

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