A Look to the Future: The Evolving Health Care System

The QIAs and case studies profiled in the previous chapters illustrate that health care organizations are rising to the challenge of successful diabetes management. The future holds promise for continuing to improve care by applying new research as well as existing knowledge to the complex task of managing diabetes and its complications. Even preventing type diabetes is a possibility within reach for many Americans if health care organizations commit to focusing on the growing problem of overweight and obesity. Another important way to enhance diabetes care is to focus on the health care system itself and examine other models of care.

A health care system designed to manage acute illness often does not meet the needs of patients for effective clinical management, psychological support, and information. Evidence is mounting that strategies to improve the quality of chronic care are effective and vital to improving diabetes outcomes. The chronic care model (CCM) is the key to quality improvement that incorporates this evidence.^[1]

In the CCM, the health system is part of a larger community, and each clinical practice is part of the whole system.1 The essential elements of a health care system that encourage high-quality care are links to community resources, leadership for changes in the health system, support for patient self-management, effective design for delivery of care, support for physician decisions, and efficient use of clinical information systems (Figure 1).^[1]

These elements can foster productive interactions between health care providers with resources and expertise and patients who take an active part in their own care.^[1]

Figure 1. Overview of the Chronic Care Model[2]

Health care organizations can do their part to address gaps in diabetes care by committing to systemic support for the elements of the CCM. A successful transition to the CCM starts with the leadership and reaches to all levels of the organization.^[1]

• The health system
• Providing visible support and promotion by the organization’s leaders for effective quality improvements
• Setting goals and measuring accomplishments
• Providing incentives based on quality of care
• Encouraging open and systematic handling of errors and problems
• Initiating agreements to facilitate communication and coordination of care within and across organizations
• The community
• Forming links to community agencies for special services and negotiating and collaborating with other health care organizations for expanded continuity of care (community linkages are especially helpful for smaller organizations)
• Advocating for public policies to improve care
• Self-management support
• Supporting self-management strategies, including assessment, goal-setting, action planning, and problem-solving
• Promoting a shift from didactic patient education to individual and group interventions emphasizing self-management
• Delivery system design
• Adding clinical case managers (nurses or pharmacists) to the clinical care team and/or improving management of team coordination
• Giving care that patients understand and that fits with their cultural background
• Decision support
• Embedding evidence-based guidelines into daily clinical practice
• Sharing evidence-based guidelines and information with patient
• Educating practitioners and integrating specialist expertise
• Clinical information systems
• Increasing the use of registry and other electronic reminder systems to help caregivers integrate diabetes clinical guidelines into daily practice and coordinate care
• Tracking patients to identify those who need proactive care
• Monitoring the performance of care teams and systems

Electronic Medical Record System Drives Patient-Centered Care Extracting information from paper medical records for quality improvement and real-time patient management is almost always difficult, time consuming, and resource intensive. In 2001, a primary care physician group with 32 physicians practicing in eight offices in a large metropolitan area invested in an electronic medical record system, and is using it to drive and measure their QI efforts. The system helps the group’s physicians obtain trended patient information on lab results and treatment at the time of the office visit. Physicians use this tool to assess progress and to help patients understand the impact of their treatment plan. Patients who are adhering to treatment can see the results and receive real-time, positive feedback from their physician. If their diabetes is not in control, the report becomes the basis for discussion between the physician and patient to determine what the barriers are. The group also uses the system to extract data to compare performance of all physicians within the group, as well as with external benchmarks. Using the data, several of the group’s physicians were able to improve their performance and obtain three-year recognition through the NCQA/ADA Diabetes Physician Recognition Program. The recognition has paid off through positive publicity, new patients, and additional compensation from an employer group participating in the Bridges to Excellence program (the additional compensation is shared among the physicians who achieved the recognition). The group’s CEO believes that the electronic medical record system was a valuable investment that has helped position the organization to meet the challenges posed by physician-level performance measurement and to demonstrate the excellent quality of care provided by its practitioners.

Health care organizations have a unique opportunity to influence the health of Americans in the future by evolving a system of care that can provide quality preventive, acute, and chronic care. An unwavering commitment by leaders to organizing services around patient needs and to motivating health care providers to make quality their top priority constitutes the basis for transforming the health care system.

To move toward the goal that the CCM embodies and meet ADA guidelines for diabetes care, health care organizations and professionals must adapt health care processes from a focus on acute, episodic care to a broader system that supports prevention and chronic care. Many elements of the CCM are within immediate reach of health care organizations. NCQA’s newest physician recognition program, Physician Practice Connections (PPC), provides an opportunity for physicians to demonstrate how their practices reflect key elements of the CCM. See page 85 for more information on the PPC.

The HEDIS^® data tell us that diabetes care is improving, but too many patients with diabetes are not getting the care they need to live full, active lives. Making bold choices for treatment initiatives that will prevent or delay diabetes and lead to the highest quality chronic care are the keys to slowing the epidemics of obesity and diabetes. All health care stakeholders can emulate the quality initiatives and case studies in this edition of Quality Profiles: Focus on Diabetes by adapting them to fit the needs of their constituents.

The multiple complications of diabetes led the health plan featured in this Quality Profile to develop a multipronged approach to managing this disease.

In 1999, the health plan identified diabetes in 3.1% of its commercial population and 14.8% of its Medicare population. While these figures were lower than national prevalence rates for the general population of 6.3% overall, 18.3% in adults over age 63, the plan felt that diabetes should be a focus for analysis and intervention.

Because HEDIS results provide organizations with the means to compare their diabetes outcomes with other MCOs across the country, the health plan compared their HEDIS results for diabetes with the national and/or regional benchmarks at the 90th percentile. The plan discovered that its results were below the benchmarks. Therefore, in addition to prevalence, the health plan was compelled by these less than satisfactory HEDIS results to develop a systematic approach to enhancing diabetes care for its members.

In 2000, the MCO elected to focus on a subset of the HEDIS measures where performance was lower than benchmark and, therefore, demonstrated the greatest opportunity for improvement. Primary concerns were the two control measures, since these represent actual outcomes in care, versus the other measures that focus on the process of receiving or providing care. The health plan believed that if results of outcome measures improved, then process measures results would naturally follow. It was also particularly interested in the measures associated with cardiac care, since the literature shows a high correlation between diabetes and heart disease.

The HEDIS^® measures used in this study assessed the percentage of adults, aged 18 to 75 years, with diabetes (type 1 and type 2) who had the following in a given year:

• Poor hemoglobin A1c control (>9.5%)*
• Lipid (LDL) screening
• Lipid control (LDL <130 mg/dL)*
• Retinal eye examinations

*Note: In 2004, the National Committee for Quality Assurance (NCQA) modified the control level for HbA1c to >9.0% and added another control measure of LDL <100 mg/dL.

The health plan decided to use the national and regional benchmark results for each of these HEDIS^® measures as its goal. The goals for each measure and product line beginning in 2000 are found in Table 1.

Data were collected using a hybrid methodology that included medical records and administrative claims data. This method of data collection is necessary for diabetes measures since administrative systems are unlikely to contain all of the required components of the measures. Table 2 summarizes the results compared with baseline.

The health plan formed a Diabetes Lead Team comprising two medical directors, three nurses, and a data programmer/analyst. The Diabetes Lead Team was charged with implementing a diabetes management program in response to baseline results and was given input from the Internal Medicine Clinical Advisory Committee (IM-CAC), a group of network practitioners. In addition, the plan collaborated with a large multispecialty group practice with 14 delivery sites that cares for approximately 25% of the plan’s members.

The Diabetes Lead Team identified barriers, including:

• Patients do not have sufficient knowledge of diabetes.
• Patients are lacking in self-management skills.
• Patients need more information on how to access care.
• Patients aren’t assuming responsibility for their care.
• Little time is available during office hours for physicians to provide the necessary education and self-management training for patients.
• There is a need for greater collaboration between practitioners and patients in diabetes management.
• Physicians do not know and/or comply with the most current diabetes guidelines.

The health plan decided it would focus on implementing a comprehensive disease management program to address the wide array of patient and physician barriers. The health plan ensured that the multispecialty group practice offered the same scope of services and outreach efforts as the health plan program. Through this collaboration, the health plan was better able to direct resources where they were most needed.

Multispecialty group practice interventions included:

• Focused educational mailings to patients with diabetes. Patients with A1c <8.0% were sent a one-time mailing, while those with A1c >8.0% received bi-monthly mailings.
• Reminders encouraging members to seek needed services were mailed.
• Personalized letters were sent to members with overdue tests.
• Ongoing clinical training and meetings with diabetes educators and practitioners conducted by the health plan staff were instituted to improve diabetes care.

After considering the barriers, the organization developed the following interventions for members not enrolled with the multispecialty group practice.

Member-Focused Interventions

• Diabetes Control Network™ (DCN): Mailings of targeted diabetes educational materials were sent monthly to members who voluntarily elected to enroll in the DCN. Each month a different topic about diabetes was presented.
• Diabetes wallet cards listing key questions for members to ask physicians during office visits were mailed to members (see Appendix 9).
• An interactive diabetes Web site with educational content, tools (quiz to test knowledge and diary to record blood sugars), and online access to nurses was established.
• A diabetes nutrition video was created by the health plan and filmed at a local grocery store with a dietitian explaining appropriate food selections and portion control. The video was available during health plan-sponsored diabetes community events and used as an educational tool by the health plan’s nurse educators.
• Outreach by a nurse educator to high-risk members with diabetes, defined as those with comorbidities of ischemic heart disease and hypertension, or those referred by their practitioner. Nurse educators provided telephone contact to review the information sent to the member and provided more in-depth education based on the individual member’s needs. A patient registry was provided to PCPs to assist them in tracking and monitoring progress of their patients with diabetes.
• Community outreach events were sponsored in collaboration with a local grocery store. These events included onsite diabetes education provided by a pharmacist, a dietitian, and a podiatrist. In addition, blood glucose testing was done and education on the proper use of glucose meters was provided. Local Lions Clubs sponsored a mobile van with an ophthalmologist to do eye examinations. Several events were scheduled throughout the year and offered to anyone with diabetes, not just health plan members. Local advertising was used to promote participation, and all members with diabetes received notification through the mail.

Quality Awards Program Quality Awards is part of the health plan’s pay-for-performance program and a unique way for medical groups to acquire funding for QI projects, including diabetes. Practitioners complete a grant application (see Appendix 10). A blinded peer review process considers applications based on a variety of criteria, including relevance of the project to members, ability to impact health improvement, and sustainability of the approach. Practitioners applying for the grant do not have to show improvement to receive funding, but do need to demonstrate a reasonable expectation that improvement in care is likely. The funding for QI projects is limited to providing resources to get the project started, not to sustain it over time. Resources are provided to initiate programs that group practices might otherwise not be able to afford, such as purchasing equipment or acquiring educational materials. Funds are not used for ongoing expenses, such as staffing. The size of the grant is proportionate to the number of the members enrolled with the medical group and the scope of the QI project. The program is very popular with practitioners, and the health plan awards $2 million in grants annually.

• A diabetes clinical practice guideline was developed and distributed in collaboration with the Department of Public Health. All MCOs in the state participated in this effort to provide physicians with one guideline supported by multiple organizations.
• A Quality Awards program provided financial support to medical groups that implemented diabetes QI projects (see detailed summary on previous page).
• Educational workshops offered to practitioners stressed the importance of the management of cardiovascular disease and hypertension, and of adding aspirin to the treatment plan. These workshops featured experts in the field of diabetes and showcased some of the local practices that had developed programs for Quality Awards.

The first remeasurement was reported in 2001 based on data from January 1, 2000, to December 31, 2000 (Table 3). There were significant gains achieved in every measure for both the commercial and Medicare products. None of the results achieved the health plan’s goals, which were based on the most recent HEDIS^® benchmark results. The Diabetes Lead Team concluded that a large portion of these improvements may be a result of earlier efforts of the multispecialty group practice that had implemented the disease management program in the fall of 1999, a full year before the health plan’s program. The group practice now accounted for 31% (8,911/28,931) of the total adult membership with diabetes. Based on a review of the group practice’s program, the health plan identified the need to enhance practitioner interventions and develop similar approaches.

The Diabetes Lead Team consulted with practitioners on the IM-CAC and identified several new barriers:

• The physicians lacked information about members who were not receiving the recommended tests and examinations.
• Confusion existed about referral requirements for annual dilated eye examinations.
• Practitioners lacked time in their offices to provide all services needed by members with diabetes.

Barriers identified at baseline, along with these new issues, formed the basis for interventions planned for 2002.

All interventions implemented between 2000 and 2001 were continued. The health plan then developed strategies to address new barriers to care: 1) physicians would receive case listings quarterly with their members with diabetes identified and notification of overdue tests or examinations; 2) members would receive annual notification of their diabetes tests or examinations and be encouraged to get tested if overdue; ^[3]) practitioners would be educated about eye care benefits and letters would be sent to ophthalmologists reminding them that a referral for dilated eye examinations was not needed; and 4) coordination between nurse educators and care managers would be enhanced to target members with diabetes with special health care needs. The nurse educator would work with the member to improve knowledge and self-management skills based on the unique health care issues identified by the case manager.

All performance indicators improved again based on data from January 1, 2001, to December 31, 2001 (reported in 2002) (Table 4). In general, goals were not met for the Medicare product, with the exception of eye examinations. In 2002, new benchmark data was available for the Medicare + Choice population, and new stretch goals were established based on this information.

Multiple interventions were credited with the gains in performance observed in 2002. By this point, the health plan had conducted 11 community outreach programs in local grocery stores reaching 523 health plan members (total participation was much higher as it included nonhealth plan members). Nurse educators and case managers continued to work with all high-risk members with diabetes to ensure coordination of services, and physicians received more detailed information about each patient and his or her testing needs.

The Diabetes Lead Team modified the case listing for practitioners by adding a space for the physician to indicate if the patient needed care management. The physicians were instructed to fax back the lists to the nurse educators for follow-up. This process allowed the nurse educators to focus their efforts on members with diabetes known by practitioners to have more serious health issues or members who were newly diagnosed with diabetes.

In addition, the health plan modified and distributed the Type 2 Diabetes Treatment Approach Principles flowcharts of the statewide diabetes guidelines to include drug trade names to make it easier for practitioners to read and follow. The health plan also developed and distributed diabetes stickers for practitioners to affix to medical records of members with diabetes as an identifier and reminder of the clinical guideline recommendations for diabetes testing. The multispecialty group practice was also first to produce quarterly practice-site level reports on HEDIS diabetes measures based on its electronic medical record system.

All previously described interventions continued, and new or revised interventions were implemented and included:

• Financial incentives for practitioners meeting specific diabetes performance targets—“pay-for-performance”
• Modifications to the identification of high-risk members with diabetes for more intensive nurse follow-up

Many improvements were reported in 2003 for measurements in both the commercial and Medicare populations (Table 5). Goals were met for poor A1c control in the commercial population and exceeded for eye exams in the Medicare population. It is also important to note that although the plan did not meet its goals, the health plan met NCQA’s 90th percentile for accreditation.

Clearly, the health plan’s efforts to improve diabetes management were succeeding. Critical to these efforts was the significant outreach to both members and practitioners through multiple types of focused interventions, including tracking members through a registry and using nurses to educate and manage services. Intensive education for both members and physicians was provided using all available means (telephone calls, mailings, visits in person, and the Internet).

This health plan relied heavily on collaboration with other delivery systems (e.g., the multispecialty group practice), organizations with support services for diabetes, the public health department, and community organizations to deliver a diabetes program that incorporated best practices and input from multiple sources. This collaboration allowed the health plan to conserve resources and be more efficient in the delivery of services that were targeted to members’ specific health care needs.

The health plan has continued all of its efforts to improve the treatment and outcomes for patients with diabetes, and results have been maintained. The results for 2004 (from data from January 1, 2003, through December 31, 2003) are provided in Table 6.

Efforts at this point are focused on refining existing approaches and identifying new opportunities. Previous methods of identifying high-risk members with diabetes (e.g., those with increased cardiovascular risk or those who were referred by their practitioner or care manager) were not producing optimal outreach.

As a result, the approach to identification was refined using predictive modeling and pharmacy data. Beginning in 2003, a new e-health program for diabetes and coronary artery disease was piloted to identify high-risk members for nurse-educator and care-management interventions. High-risk members were defined as members with diabetes who had a recent prescription for specific cholesterol or cardiac agents or members with coronary artery disease risks who had a recent diagnosis of diabetes and a recent prescription for a diabetes agent. As a result, new data became available on a monthly basis for the nurses to perform outreach.

The health plan featured in this Quality Profile demonstrates that a comprehensive disease management approach, continued and refined from year to year by reevaluating barriers to success, can improve care and reduce cardiovascular risk factors for members with diabetes.

Shared Medical Appointments Improve Patient Education and Satisfaction Many physicians and patients find that the typical 15-minute physician visit is not satisfactory. A local nonprofit health care agency serving rural counties is helping physician practices successfully implement shared medical appointments (SMAs, also called group medical visits), a QI initiative recommended by the American Diabetes Association (ADA) as a “strategy for improving diabetes care” in its 2004 Clinical Practice Guidelines. SMAs bring together a group of patients and a multidisciplinary health care team including a physician, nurse, and others such as a pharmacist or dietitian. Typically, the agenda includes individual patient assessment and check-in, an individual physical exam and a medication review by a provider, a group discussion and education about a self-care topic, a question-and-answer time, and a planning period for the next group visit. Group visits usually range from 90 to 120 minutes, depending on the individual practice. Extended individual patient visit time with the physician is available after the group visit for the patients who need it. The agency began the project by working with one physician group that requested assistance in implementing SMAs with its patients with diabetes. The physician group is located in a rural area with a high prevalence of diabetes and a large incidence of patients with diabetes in the practice. Using resources and tools from the Institute for Healthcare Improvement Web site, the facilitator worked with the practice for three to four months to define the process for conducting SMAs and to address the logistical and planning issues to ensure success. Preparation involved defining roles and responsibilities for the health care professionals participating in the visit, identifying an “SMA Champion,” locating educational materials to use during the visits, identifying space within the clinic to use, blocking out time on the physician’s schedule, and identifying and inviting patients to participate Both patients and physicians who participated reported greater satisfaction with the SMA encounter process than with individual appointments. Patients reported that the SMA process helped them get all their questions answered and improved their perception of how much their physician valued the interaction with them. Patients also stated that they preferred the group visit to a regular doctor’s visit and would recommend it to others. After the success of the first physician group, the agency held an educational program, sponsored by a pharmaceutical company, for other physician practices across several counties to explain how SMAs work and the steps required to implement them. The keynote speaker was a physician-leader from a large urban multispecialty clinic that had successfully put SMAs into practice. As a result of this educational program, 15 additional practices expressed interest in exploring how to implement SMAs within their group. The state Medicaid agency is supportive of SMAs as a possible way to improve care for Medicaid patients with diabetes. Those involved with this initiative feel SMAs afford a unique and valuable way to deliver care in that attendance is usually excellent, and there is an opportunity for extended education time with the provider and other experts. Providers can more easily provide care in accordance with the ADA Clinical Practice Guidelines, and the peer support seems to really motivate behavior changes in patients

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2. Improving Chronic Illness Care. Overview of the chronic care model. Available at: http://www.improvingchroniccare.org/change/model/components.html. Accessed March 29, 2005.

3. American Diabetes Association. Diabetes statistics for seniors. Available at: http://www.diabetes.org/utils/printthispage.jsp?PageID=STATISTICS_233185. Accessed March 19, 2005.