When patients with diabetes, thyroid conditions, and other serious hormonal disorders need high-level, specialized care, they come to highly-trained endocrinologists like Helen Lawler, MD, of the University of Colorado Department of Medicine and her colleagues. But when a patient’s condition is well controlled and the need for specialized care is over, what’s the best way to help them to transition back to their primary care practitioner?
It’s an important question, particularly since specialty clinics often have limited capacity to accept new patients, given their volume of current patients.
Lawler – an associate professor in the CU Division of Endocrinology, Metabolism and Diabetes – and her colleagues have been addressing the question by developing a smoother process for “patient graduation” from the specialty clinic to the primary care practitioner (PCP). Her work aligns with her roles as her division’s director of quality and patient safety and as a member of the Department of Medicine Quality Council.
“More than 10 years ago, when I joined the endocrinology division, I realized there was no universal system in place to graduate patients back to their primary care doctor,” says Lawler, who practices at the UCHealth Diabetes and Endocrinology Clinic. “Everybody was doing their own thing. So when I got this quality role through the Department of Medicine, it gave me the means to discuss this with others and come up with a plan.”
Lawler says that capacity issues at the endocrinology clinic were a key motivation for the project. A shortage of endocrinologists, coupled with a growing demand for endocrine care, contributed to three- to six-month wait times to get new patients into the clinic, “and that’s just not acceptable,” she says.
At the same time, she says, many patients with well controlled conditions on set doses of medications were still being seen at the clinic when their cases could readily be managed by a PCP.
“From the get-go, we realized that we’re holding onto patients who could go back to primary care, whereas our care was really needed by patients who were waiting for months to see us,” she says. “So the idea is to graduate stable patients back to primary care and open up access for those patients who truly need us.”
Lawler saw the need for clear guidelines on which patients are suitable for graduation to PCP care, a streamlined graduation process, and improved patient-handoff communication by the specialty clinic with PCPs who would be continuing patients’ care and managing their prescriptions.
Starting in late 2022, Lawler met with hospital and medical group leaders at UCHealth, the Department of Medicine’s clinical partner, about developing an endocrine patient graduation system. A committee was formed to work on the project, including developing criteria for patients eligible for graduation.
Through 2023, the project developed a standardized graduation process, created a welcome note for new clinic patients and a tip sheet for providers explaining the process, and made changes to patient notes and records to indicate graduation status.
The new criteria for graduation say patients must have a PCP, their disease state should be well controlled through a stable medication regimen, and there must be a detailed plan for future care.
Patients eligible for graduation are told how graduation works and that their future visits and future medication refills will be handled by their PCP. Their graduation status is indicated in a clinic note routed to their PCP. And patients are told they can ask for a new referral from their PCP if they need specialized endocrine care again.
The new graduation process was launched in the endocrinology clinic in February 2024. As of June 1, 2025, according to data provided by Lawler, 147 endocrine patients have graduated under the new program, and only one has been re-referred back to the clinic. About 45% had type 2 diabetes, 13.4% had hypothyroidism, 6.7% had hyperthyroidism, and the rest had other conditions.
Lawler calculates that the 147 graduates averaged 2.33 provider visits per year under the endocrine clinic’s care, so their graduation made available 342 visits per year in clinic patient capacity.
In surveys conducted as part of the project, 27 of 31 graduated patients who completed the survey said they were satisfied with the process, as did 21 of 28 PCPs of graduated patients.
“Sometimes the primary doctors are a little nervous about patients coming back from specialty care,” Lawler says. “I reassure them that we would not graduate someone who is not doing well and if anything, we tend to hold on to patients too long who are stable and no longer need our care.”
When Lawler presented the project to the Department of Medicine Quality Council in 2024, its chair, Anunta Virapongse, MD, MPH/MSPH, adopted the graduation process for eventual use by all medical subspecialties as a quality initiative.
“Everyone has lots of referrals, and this can help them open up spots for patients who truly need them,” Lawler says.
As a next step to make the graduation process even simpler, work is underway to create a “graduation button” in the Epic electronic medical records system used at UCHealth, allowing clinic providers a simplified way to indicate that graduation criteria have been met.
“The system we have in place now isn’t too difficult, but the providers do have to remember to do the various steps correctly,” Lawler says. “Having a button will make it easier, and I think then we’ll have even more graduates.”
Lawler is gratified by the high level of acceptance of the new program by graduated patients. When a transfer back to a PCP is discussed, she says, “sometimes patients say, ‘Wait a minute.’ And we encourage them. We say: ‘You’re doing great. Your primary doctor’s got you.’ And the good thing is, we have some amazing primary care doctors out there.”
Lawler grew up with a PCP role model: Her dad, a retired internist. “My father was the epitome of loving medicine and enjoyed helping people. I wanted to follow in his footsteps.”