Issa Fakhouri, MD

Internal Medicine, KP Stockton

Diabetes Care Management

“I wanted to disrupt the conventional practice of episodic care—the model in which people get help only when they are sick. We must work further upstream, so that people with diabetes, for instance, receive consistent, proactive care.”

Less than a decade ago, Kaiser Permanente Northern California ranked in the low 100s in the country for diabetes management. But thanks to a program Dr. Fakhouri implemented in the Central Valley and then helped spread throughout the region, KP Northern California now ranks in the top 5.

For Dr. Fakhouri, who grew up in Stockton, diabetes is personal. His grandfather had diabetes and high blood pressure and received sporadic, inconsistent care, which ultimately led to an early death in his mid-50s. When he joined The Permanente Medical Group in 2000, he knew he wanted to make a difference by ensuring patients with diabetes get the very best care.

Dr. Fakhouri flipped the conventional model of diabetes care management, in which 95% of patients with type 2 diabetes consulted with their primary care physician, and 5% whose blood sugar was not in good control partnered with a chronic condition manager. Under the new structure, patients who found it more difficult to manage their diabetes continued to consult with their primary care physician, and the remaining 95% with type 2 diabetes got help controlling their condition from an accountable care manager (ACM) or physician extender, who is a pharmacist or registered nurse.

Once the program was successful in the Central Valley, Dr. Fakhouri helped get more than 216,000 patients throughout KP Northern California connected with their local ACM. Today the majority of patients with diabetes have a dedicated pharmacist or nurse who partners with the patient’s personal physician to provide long-term, consistent, and comprehensive care.

“Dr. Fakhouri implemented a program in which all patients, rather than only the sickest ones, get appropriate education and care for their diabetes,” says Sameer Awsare, MD, TPMG associate executive director. “His tremendous passion for and commitment to delivering exceptional and highly efficient care has translated into better outcomes for patients, including fewer heart attacks and strokes.”