Partnership For
Health Management

Diabetes Management Program

The Clinical Directors chose Diabetes as the second program-wide quality improvement initiative in 2000. Following the guidelines for selecting a QI initiative, the decision was based on the following:

• There is a high percentage of adults with a diagnosis of diabetes with inpatient admissions and emergency department visits.
• Diabetes is one of the predominant diseases in the adult Medicaid population and the incidence is increasing.
• Poorly managed / uncontrolled diabetes may lead to multiple serious and costly long term complications.
• Evidence based best practice guidelines for the care of diabetes is evident and accepted in the medical community.
• There was room for improvement in the management and care of enrollees with diabetes in our networks.

Core Elements of the Diabetes Management Program

The planning and development of the Diabetes Disease Management Program occurred in 2000 and the program began the implementation phase in January of 2001. The initial base-line audit reflects the last six months of 2000. As in other quality improvement efforts, the identification of and leadership by a "diabetes champion" is a critical component to successful implementation.
Below are five steps you can take for help:

Step One: Definition of Diabetes

• Determine diagnostic criteria for Diabetes Mellitus for non pregnant adults
• Diabetic Testing:
• A random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L) or
• Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) after 10-12 hr caloric abstinence or
• 2 hour plasma glucose during OGTT (Oral Glucose Tolerance Test) greater than or equal to 200mg/dL (11.1 mmol/L)
• Impaired glucose tolerance as a risk factor
• Hospitalization for Diabetic Ketoacidosis (DKA)

Step Two: Identify and Implement Your Diabetes Team(s)

• Define and assemble a collaborative multi-disciplinary diabetes health team at the Community Care of North Carolina network level.
• Define the "Diabetes QI Champion" in each practice.
• Develop a role delineation/job description for your Diabetes QI champion.

Step Three: Define and Develop Diabetes Resources and Tools

• Identify and develop/customize tools for the providers and the patients on diabetes management.
• Define the practice assessment process to determine the patient's needs and assets.
• Develop a diabetes education program that maximizes diabetes self-care behavior.
• Circulate draft educational and management tools to providers and their staff for input and buy-in.

Step Four: Work with Community Resources

• Identify and collaborate/coordinate with existing community resources focusing on Diabetes.
• Identify resources and processes for hospital to community transition for newly identified diabetics.

Step Five: Educate Providers, Facilitate Buy-In, and Implement Processes

• Provide technical assistance to practices for implementation of PDSA cycles targeted to improve provider processes and patient outcomes.
• Finalize tools and processes for Diabetes disease management and educate all providers/staff in your network.
• Work with practice level "Diabetes Champion" to track and monitor program implementation.
• Identify new and ongoing needs for provider and staff education on the management of Diabetes.

Diabetes Management Program Performance Measures

The CCNC network leadership chose the following outcome measures:

• Inpatient Admission Rate
• Inpatient Admission Rate for Diabetes
• Emergency Department Utilization Rate
• Emergency Department Utilization Rate for Diabetes

The following process measure were chosen for adults and children, as indicated by ADA Guidelines:

• Diabetic Flow Sheet in use on the medical record
• Continued care visits at least 2 x year
• Blood pressure at every continuing care visit
• Referral for dilated eye / retinal exam every year
• Foot exam every year
• Monofilament / sensory exam every year
• Glycosylated Hemoglobin (HgbA1c) at least 2 in 12 months
• Annual Lipid profile
• Annual Flu Vaccine
• Pneumococcal vaccine done once (repeat IF first dose was given at less than 65 yrs. old AND pt. is now greater than 65 AND first dose was given more than 5 yrs ago)

Heart Failure Program Performance Measures

The Community Care of North Carolina network leadership chose the following outcome measures:

• Heart Failure Hospitalization Rate
• Heart Failre Re-admission Rate
• Heart Failure Emergency Department Utilization Rate
• Mean Heart Failure Enrollee Cost

And the following process measures were chosen:

• Percent Heart Failure Patients with Echocardiogram in past 3 years
• Percent with Ejection Fraction greater than 40%, prescribed ACE Inhibitor or ARB after identification with heart failure
• Percent with Ejection Fraction greater than 40%, prescribed Beta Blocker after identification with heart failure
• Percent of those prescribed ACEI or ARB, filling prescription at least 80% of months in claims database
• Percent of those prescribed Beta Blocker, filling prescription at least 80% of months in claims database