Timing is everything when it comes to empowering patients to take control of their health. 

For members of Hawaii’s Patient Support Services team, that means contacting patients with diabetes right after hospitalization. 

“One of the most impressionable times to work with a diabetes patient is immediately following discharge,” explains Shelley Kikuchi, the team’s management co-lead. 

By reaching out to patients during those “moments that matter,” the team has increased the number of diabetes patients with blood sugar levels under control. Their practices have proven so effective they are now part of routine treatment for patients with diabetes regionwide. 

“The close follow-up with patients helps us better manage their medication and support their healthy lifestyle choices,” says Alana Busekrus, RN, the team’s labor co-lead and a certified diabetes care and education specialist who is a member of the Hawaii Nurses and Healthcare Professionals (HNHP) union. 

To help patients manage diabetes, the team monitors their blood sugar levels, orders lab tests, adjusts medications and offers advice on nutrition and exercise. These interventions are important because Native Hawaiians and Pacific Islanders are among those at higher risk of diabetes, a serious chronic disease.

Overcoming obstacles 

But achieving success wasn’t easy. 

Early efforts to provide post-discharge care proved labor intensive and fell short of regional goals for controlling patients’ blood sugar levels, recalls Anna Sliva, RN, a care manager with the team and an HNHP member. 

Health outcomes improved after unit-based team members standardized the discharge process in 2019. Nurses collaborate with Transitional Care clinical pharmacists to identify high-risk diabetic patients before they leave the hospital. Care managers follow up by showing patients how to use glucose monitors to track their blood sugar levels. 

Results were significant. Within 3 months after discharge, 30% of patients lowered A1c blood sugar levels by at least 0.5 percentage points. And within 6 months, 50% of patients lowered A1c levels by at least 1 percentage point. 

“Thanks to our team’s excellent work,” says Kikuchi, “the ‘moments that matter’ discharge workflow has become a standard part of our practice, benefiting some of our most vulnerable diabetic patients.” 

When it comes to addressing health care disparities, medical office assistant Anna Jenkins thinks her unit-based team is up to the challenge. 

“I can go to my UBT members and say, ‘This is a care gap. Give me your feedback. Give me your ideas,’” says Jenkins, an OPEIU Local 30 member and labor co-lead for the Rancho San Diego Primary Care team. “Our administration listens to us. They’re very open to letting us try it our own way.” 

The Level 5 team is leveraging Labor Management Partnership principles and tools to communicate, coordinate and customize care for Latino patients with diabetes. The approach has led to better health outcomes and improved service for a group disproportionately impacted by diabetes. 

The unit-based team has increased the number of Latino patients ages 65 to 75 whose blood sugar levels are under control, according to recent clinical quality measures. 

“That partnership between management and labor is important,” says Silvia Hernandez, RN, medical office administrator and the team’s management sponsor. “This teamwork helps us to improve patient care and quality with excellent member satisfaction.” 

Adapting approaches 

Key to the team’s success is partnering with Complete Care Management, a specialized strike force that monitors the health of patients who struggle to control chronic conditions, such as diabetes and high blood pressure. 

To better support her Latino patients, care manager Lily Thamiz, RN, has adapted her approach. She books longer appointments for Spanish-speaking patients who need interpreters, refers others to bilingual diabetes education classes, and relies on phone calls to connect with those short on time. 

“The only time we can talk is when they’re driving,” says Thamiz, a member of Specialty Care Nurses of Southern California, an affiliate of UNAC/UHCP. “These are solutions I’d never considered before.” 

UBT members tailor treatment in other ways, too. To ensure continuity of care for Latino patients in their 60s and 70s, they standardized the steps needed to download and share data from glucose monitors. Providers use the devices to track patients’ blood sugar levels and adjust their medications. By consistently managing and sharing data, staff members guarantee they do not miss crucial patient information when communicating with one another. 

“They make you feel like you really matter,” says Mary Hart, 71, a Latina patient who has diabetes. “They really show their concern for your health.”

Aparna Gulati, MD, was growing alarmed. Many African American patients with high blood pressure were missing their doctors’ appointments.

“Due to COVID-19 fears, many of our patients weren’t coming in for even a blood pressure check,” said Dr. Gulati, medical director of Chronic Conditions Management for the Greater Southern Alameda County area in Northern California.

“African Americans are at the highest risk for all kinds of morbidity due to hypertension.”

Nationally, more than 40% of African Americans have high blood pressure — a rate much higher than other racial and ethnic groups.

Like providers across Kaiser Permanente, Dr. Gulati is working to reduce the disparity. In November, she and her team collaborated with Coalition union members to host 2 free blood pressure fairs for African American patients with hypertension.

Cashier service receptionists, members of OPEIU Local 29, called nearly 2,000 patients to notify them about the event. Lab workers from SEIU-UHW also provided their services.

“Many of our patients have critical needs,” said receptionist Alexis Machado, who worked at both events. “They might have slipped through the cracks if they hadn’t shown up. They all seemed happy to be here and get their preventative screenings taken care of right then.  It was very rewarding for me.”

Meeting patients’ needs

In all, 500 African American patients drove up to receive blood pressure checks. Flu shots, lab tests, mammograms and colorectal cancer screening kits also were available.

“We can both get our blood pressure checked without getting out of the truck,” said Kaiser Permanente member Tanya Leno, as she and husband William Leno drove through the outdoor event.

Organizers were thrilled with the turnout — and results. About 25% of patients with high blood pressure didn’t have it under control and needed their medication adjusted. They also received follow-up appointments.

“We used the opportunity to teach patients the importance of measuring blood pressure and keeping it controlled, investing in a blood pressure machine, and following up with their physician,” said Dr. Gulati. “Coming from a physician, it tends to stick more, and will hopefully increase awareness.”

Emile Pinera, MD, a second-generation Kaiser Permanente employee, came to the company five years ago and immediately became co-lead of an adult medicine unit-based team in the Georgia region.

“I had the clinical part down,” says Pinera, who is now lead physician for diversity and inclusion in Georgia and an adviser on the region’s transgender task force. But being a co-lead and working in a UBT were unfamiliar. “I had to implement my medical knowledge in a team, as opposed to a top-down approach where the doctor tells everyone what to do.” 

He wasn’t convinced at first—but the partnership approach and physician participation helped elevate the team’s performance, and it posted some of the region’s highest quality scores for managing diabetes and blood pressure. 

“We achieved it through hard work and collaboration,” Pinera says. “I loved working with my management and labor co-leads. We were respectfully honest about what was achievable. Working in the UBT gave us the tools to effectively communicate, track, adjust and improve.”

Pinera currently guides and supports co-leads as a UBT sponsor for three teams and is lead physician for three adult medicine offices. His enthusiasm helps his teams, the members and the Georgia region. 

“I was skeptical at first about UBTs’ relevance, but we couldn’t achieve our success with hypertension and diabetes management without each other’s help. I’m a believer,” he says. “My tip for fellow providers is to be engaged as much as possible, because it will help us achieve better outcomes and help our patients thrive.”