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.”