Diabetes Care Best Practices Compendium

Diabetes Care Best Practices Compendium

Diabetes Care Best Practices Compendium

Medicaid Health Plans of America Center for Best Practices DIABETES CONTROL Diabetes Care Best Practices Compendium

Diabetes Care Best Practices Compendium

table of contents | 3 Table of Contents Welcome About the MHPA Center for Best Practices . 5 Welcome Letter: A Message from Michelle Martin . 7 Chapter 1: About Diabetes . 8 Chapter 2: Diabetes Prevention . 12 Chapter 3: Reducing Diabetes Racial and Ethnic Disparities . 13 Chapter 4: Medicaid Health Plans – Innovations in Improving Diabetes Care . 16 Chapter 5: Health Plan Best Practices . 21 Buckeye Community Health Plan and AT&T mHealth Solutions Presents DiabetesManager® [Buckeye Community Health Plan (Centene® Corporation) and AT&T/WellDoc . 21 Community Health Worker Program (UPMC for You . 24 Diabetes Control Network (Midwest Health Plan . 25 Diabetes Education for SMI [Nurse Wise/Nurse Response (Centene . 28 Diabetes Total Wellness Initiative: Learning to Live and Thrive with Diabetes (Amerigroup Maryland . 29 Drug Therapy Management (DTM) Program for Diabetics (PerformRx, AmeriHealth Mercy Health Plan and Keystone Mercy Health Plan . 31 Get Control It Matters (Delaware Physicians Care, An Aetna Health Plan . 34 HealthConnections: Community-Based Disease Management Pilot - Diabetes (WellCare Health Plans, Inc . 37 Healthy Families Program (Amerigroup Corporation . 38 In Control Diabetes Care Management (Select Health of South Carolina . 40 MDwise Rewards Program (MDwise, Inc . 41 The mHealth Program (DC Chartered Health Plan, Inc . 43 Monitoring for Risk of Metabolic Syndrome (Value Behavioral Health of Pennsylvania . 45 Nurtur’s Diabetes Program (Centene® Corporation . 48 VSHP Diabetes Gaps-In-Care (Volunteer State Health Plan and BlueCross BlueShield of Tennessee . 49 YOU Count (Health Partners of Philadelphia, Inc . 51 Chapter 6: Diabetes Resources . 52

Diabetes Care Best Practices Compendium

4 | Diabetes Care Best Practices Compendium About MHPA Center for Best Practices The Medicaid Health Plans of America (MHPA) Center for Best Practices (CBP) is a 501(c)(3) affiliate organization created to support MHPA’s mission: to provide efficient health care services and improve quality and access to care for Medicaid beneficiaries. The CBP serves as a convener of Medicaid health plans on research, quality improvement and dissemination of health plan best practices in both clinical and operational domains. With guidance from the leadership of premier health plans serving Medicaid populations and expert stakeholders, the CBP uses data, information and knowledge transfer to disseminate innovative solutions to caring for underserved populations. Welcome | 5 MHPA Center for Best Practices Best Practices Compendium on Diabetes Care By Liza Greenberg, RN, MPH, MHPA Senior Consultant, Clinical Initiatives Layout and design by Karen Seidman, Seidman Says Communications ~~~ The MHPA Center for Best Practices thanks the member plans that submitted best practices for this publication. We are also grateful to the other MHPA members who offered guidance, insights and comments on drafts of this document. Any errors in this compendium are the responsibility of the author. ~~~ Supported by an educational grant from Roche Diagnostics ~~~ Copyright © 2013 Medicaid Health Plans of America Center for Best Practices ~~~ MHPA Center for Best Practices 1150 18th Street, NW Suite 1010 Washington, DC 20036 Tel: (202) 857-5720 | Fax: (202) 857-5731 info@mhpa.org | www.centerforbestpractices.org

Diabetes Care Best Practices Compendium

6 | Diabetes Care Best Practices Compendium Welcome Letter A Message from the MHPA Center for Best Practices Director Michelle M. Martin Dear Colleagues: On behalf of the MHPA Center for Best Practices, I am pleased to bring you this Diabetes Care Best Practices Compendium. Diabetes is one of the most common chronic diseases affecting members of Medicaid plans. More than 8% of the U.S. population has diabetes and the risk of diabetes is higher in low income and some minority groups — precisely the populations served by Medicaid health plans. One of the key objectives of Medicaid health plans is to close these health care quality gaps and reduce disparities.

This publication provides information on best practices in diabetes care and highlights programs from MHPA health plans and partner organizations. These descriptions illustrate efforts to educate, engage, and ensure high-quality treatment for Medicaid enrollees with diabetes. Plans are offering specialized programs to identify members with diabetes, link them with care managers and health care services, and measure changes in delivery of essential diabetes treatments. Health plans are also taking a leadership role in working with communities to improve health and prevent diabetes. Plans also educate physicians and other health care providers, and often use health plan data to show providers where members are lacking in diabetes care. These patient- and provider-directed efforts help to narrow the gaps in diabetes care quality. Prevention of diabetes is a key area of emphasis for health plans. Medicaid health plans have a variety of diabetes prevention programs and collaborations to promote physical activity, encourage healthy eating, and help people maintain a healthy weight. Health plan prevention approaches are multi-faceted and include community- based strategies, programs to support clinicians in improving care, and programs to educate patients. These interventions are critical to stem the rising tide of diabetes.

This publication offers information for Medicaid health plans, state leaders, and other policymakers. It also lists resources with website links that can help readers find information about preventing and managing diabetes. We commend the health plans featured in this publication and encourage all stakeholders to work together in the fight against diabetes. Sincerely, Michelle M. Martin Director, MHPA Center for Best Practices welcome | 7

Diabetes Care Best Practices Compendium

8 | Diabetes Care Best Practices Compendium Chapter 1: About Diabetes Diabetes is a critical health issue for the United States and for Medicaid health plans. An estimated 26 million, or approximately 8% of U.S. residents have diabetes. That number is higher among racial and ethnic minority populations; almost 13% of adult African-Americans and 12% of Hispanic populations have been diagnosed with diabetes. Diabetes is also more prevalent in the elderly and low income populations — meaning that it is an important issue for health plans serving these Medicaid beneficiaries.

Also of great concern is the potential for future cases of type 2 diabetes: 35% of adults over 20 have signs and symptoms of prediabetes. Prediabetes may progress to type 2 diabetes unless people adopt healthy behaviors. It is often reversible through changes in diet and exercise resulting in weight loss. Obesity is a key driver of diabetes. With a third of the population now clinically obese, the toll of diabetes may continue to rise. Some racial or ethnic minority groups are at particularly high risk for the development of diabetes related to obesity. Preventing obesity as a nation, and treating weight problems for individuals with diabetes and prediabetes is an essential strategy. It is a national priority to improve nutrition and lifestyle — starting in childhood — to prevent obesity. National efforts to prevent diabetes often focus on developing programs and policies that will create a healthy environment that prevents obesity.

What is Diabetes? Type 1 diabetes stems from the body’s inability to make insulin which helps process glucose (sugar) for energy. Type 1 represents a small percentage (5-10%) of all persons with diabetes. Type 2 diabetes is the most common form of diabetes. Type 2 diabetes is the result of both reduced insulin secretion and reduced insulin effectiveness, conditions known as insulin resistance. Because insulin is necessary to metabolize glucose in the body, absent or insufficient insulin results in high blood sugar (hyperglycemia).

Type 2 diabetes can sometimes be controlled with diet and exercise, but medications are often required. Type 1 must be treated with insulin. Controlling diabetes will prevent damage to other body systems, including end stage kidney disease and blindness. Diabetes treatment also focuses on controlling hypertension and elevated cholesterol, which lowers the patient’s risk for cardiovascular disease linked to diabetes. Why So Much Emphasis on Diabetes Care? Diabetes affects the health and productivity of the patients and families who live with it. For most people, type 2 diabetes is a progressive disease that triggers a cascade of “co-morbidities” or other health problems. Despite knowledge of effective strategies to manage diabetes, treatment adherence Narrative | 9 to both lifestyle and medication recommendations remains low. The statistics outlined below demonstrate how diabetes contribute to poor health outcomes. For example, according to the National Institutes of Health: Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes.

The risk for stroke is two to four times higher among people with diabetes. Up to 67% of diabetics have blood pressure greater than or equal to 140/90 mmHg or use prescription medications for hypertension. Diabetes is the leading cause of new cases of blindness among adults ages 20–74 years. Diabetes is the leading cause of kidney failure, with almost 50,000 new cases each year. 60-70% of people with diabetes have mild to severe neuropathy (nerve damage), and 60% of non- traumatic amputations are in people with diabetes. 1 How Can Diabetes be Treated More Effectively?

The goal of treatment for type 2 diabetes is maintaining near normal or target range blood sugar levels and preventing complications. Successful management includes both medical interventions and patient adoption of a healthy lifestyle with nutritious eating and regular exercise. High quality diabetes care is often called “evidence-based care” because it is consistent with treatment that research evidence shows will produce the best health outcomes. Treatment goals for type 2 diabetes include: Hemoglobin A1c (HbA1c) control, with checks every three to six months Blood pressure control at 130/80 mm/Hg or lower Cholesterol and triglyceride levels management with annual checks (LDL cholesterol levels below 70-100 mg/dL) Annual kidney function tests (microalbuminuria and serum creatinine) Annual eye exams to check for diabetic eye disease, or more frequently as needed Regular dental cleanings and exams Smoking cessation treatment, if needed Adoption of regular exercise program Diabetes self-management education Standards of Care for Diabetes Type 2 diabetes is a complex and progressive condition. Treatment requires control of the diabetes-specific symptoms – high or low blood sugar – and also careful attention to preventing and treating complications.

Each year additional research results in new recommendations for diabetes treatment. The American Diabetes Association has taken the lead in convening physicians and other diabetes experts to establish standards of care for diabetes. In 2012 the American Diabetes Association partnered with the European Association for the Study of Diabetes and issued new recommendations on delivering treatments that meet the needs of specific types of patients such as the elderly, chronically ill, and newly diagnosed. This is a change from prior treatment guidelines that had a uniform HbA1c management goal for all patients.

Links to the 2012 standards, along with a summary of changes and tools to help physicians quickly identify care management goals, are identified in the Resources section of this Compendium. _ _ 1 http://diabetes.niddk.nih.gov/dm/pubs/statistics/#pdc

Diabetes Care Best Practices Compendium

10 | Diabetes Care Best Practices Compendium Recommendations for treatments are reviewed and updated each year by expert panels of the American Diabetes Association. Medication treatments are intensified as needed to achieve short-term blood glucose control, and to affect a measure of long-term control called hemoglobin A1c (or HbA1c). For patients who already have complications such as high blood pressure or eye problems, additional treatments are needed to prevent worsening of the conditions. Patients with type 2 diabetes are generally treated either with “oral hypoglycemics” (pills to control blood sugar), or injectable insulin, along with lifestyle changes such as better nutrition, exercise, and weight control. If blood glucose is not adequately controlled, additional medications may need to be added over time. Patients may need insulin earlier if blood sugar cannot be controlled with lifestyle changes and medical therapy.

For people who are severely overweight with a Body Mass Index (BMI) of 35 or over and who also have poorly controlled diabetes, obesity surgery may also be part of the treatment plan. Bariatric surgery, as it is called, has been shown to reverse diabetes in up to 80% of patients. However, bariatric surgery does have its own risks and complications. These must be weighed against the risk of complications that occur with type 2 diabetes. Quality Gaps in Diabetes Care In spite of the research showing the health consequences of uncontrolled diabetes, patients very often do not get the best quality care. These gaps in care may be the results of any combination of factors: Health care system factors: The current health care system is not conducive to working through the significant barriers experienced by patients with diabetes: visits are short, often acute illness prevents attention to routine chronic health care needs, and the system may not be set up to deliver culturally appropriate care. Often, care is poorly coordinated between the various physicians, hospitals, and other providers treating the patient. There may also be missed opportunities to improve adherence with visits and treatments and to deliver preventive treatments and counseling needed during visits. Provider Factors: Diabetes care is complex and requires visits to several different types of providers. Physicians or other providers may not offer the proper treatments, tests and checks to manage diabetes, they may not intensify treatment when it is needed, or may not offer the right education that patients need to “self-manage” their care.

Patient Factors: Patients may have language barriers, low literacy, depression or other mental health problems that make it difficult to understand or carry out their treatments. Some patients may not be ready to make lifestyle changes such as healthier eating or exercising and/or patients may experience health system/social barriers that affect adherence. All of these factors result in less than optimal “self- management,” e.g. the eating, exercising, and health management activities needed to successfully manage diabetes.

Social Factors: Patients may not have insurance coverage for the health services, medications, family support or other support services they need to effectively manage diabetes. The Medicaid program makes important strides to ensuring health care access, but members may have disruptions in care when they lose eligibility for the program. The sections below illustrate how each of the key stakeholders – patients, physicians and other providers, and health plans – can influence better diabetes care.

Amerigroup Georgia AbsoluteCARE Quality Program The AbsoluteCARE Quality Program, an Avesis company, offers a specialized patient-centered medical home for members with medical conditions such as diabetes and hypertension who do not have a strong, established relationship with a primary care physician. The medical home, created for these members through this pilot program, represents a comprehensive approach towards care that includes healthcare, wellness and prevention services. This pilot program was developed as a solution to members who were in need of recurring healthcare services but were disconnected from a primary care provider. This approach incorporates disease management services into a comprehensive, integrated patient centered medical home. The AbsoluteCARE Quality Program yielded extremely promising results. Average per member per month spending decreased by over 30% during the evaluation period. The most significant driver of savings was a decrease in inpatient care though spending increased for primary care services and prescription drug spending. Emergency room visits decreased by over 45% among participants after the referral to AbsoluteCARE was made and members opted into the program. Coordinated Care in Medical Homes May Improve Diabetes Care Best practice approaches to diabetes care often involve a multidisciplinary team. This enables providers to offer effective interventions across the diverse elements of diabetes self-care. Together these specialists cover: Nutrition and exercise Weight management Medication management Prevention and smoking cessation Other diabetes self-care behaviors In recent years many provider practices have adopted a model known as the “patient centered medical home.” Medical homes are practices that have redesigned their office operations to be more accessible to patients and to offer the full scope of multidisciplinary care needed by patients with diabetes and other chronic conditions. Medical homes also adopt more sophisticated information systems to enable them to more effectively track and meet patient’s health care needs and integrate health information with that of hospitals and specialty providers. Many experts believe that providing more coordinated care and helping members to develop connections with their medical providers will improve diabetes care quality.

Narrative | 11

Diabetes Care Best Practices Compendium

12 | Diabetes Care Best Practices Compendium Chapter 2: Diabetes Prevention Chapter 3: Reducing Diabetes Racial and Ethnic Disparities Racial and ethnic minority groups often have a higher rate of chronic diseases including diabetes and also have more risk factors such as obesity, smoking, and lifestyles. According to the National Diabetes Education Program: Non-Hispanic Whites: 15.7 million people, or 10.2 percent of all non-Hispanic whites aged 20 and older, have diagnosed and undiagnosed diabetes. 7.1 percent of all non-Hispanic whites aged 20 and older have diagnosed diabetes.

African-Americans: 4.9 million people, or 18.7 percent of all non-Hispanic blacks aged 20 and older, have diagnosed and undiagnosed diabetes. 12.6 percent of all non-Hispanic blacks aged 20 and older have diagnosed diabetes. Hispanics/Latinos: 11.8 percent of Hispanics/Latinos ages 20 or older have diagnosed diabetes. Among Hispanics/ Latinos, diabetes prevalence rates are 7.6 percent for both Cubans and for Central and South Americans, 13.3 percent for Mexican Americans, and 13.8 percent for Puerto Ricans.

American Indians and Alaska Natives: About 16.1 percent of American Indians and Alaska Natives aged 20 years and older who are served by the Indian Health Service have diagnosed diabetes. Diabetes rates vary by region, from 5.5 percent among Alaska Natives to 33.5 percent among American Indians in southern Arizona. Asian-Americans: The rate of diagnosed diabetes in Asian Americans is 8.4 percent. Quality Evaluation for Health Medicaid health plans are taking action to reduce health care disparities. For example, many plans use community data to identify communities with the highest risk factors relating to age, race, income, and health status. Health plans can develop their own care management programs and partner with community organizations to develop culturally specific programs and information on prevention and health education.

Health plans also routinely examine their own health care data to identify disparities and develop culturally appropriate prevention and treatment approaches. Many plans are making strides in improving the quality of data to enable them to evaluate quality by race and ethnicity. This will improve their ability to direct care to populations experiencing disparities in health outcomes. Prevention related to diabetes takes place on two levels. First, “primary prevention,” — preventing diabetes entirely — is an important goal. Second, for people who already have diabetes, preventing worsening of the disease or progression to heart and vascular complications is an important goal. “Secondary prevention,” as it is called, is achieved by implementing appropriate screening guidelines to ensure early identification of people who have diabetes, and by providing evidence-based diabetes care, which includes careful attention to preventing complications.

Primary Prevention: Type 2 diabetes is challenging to control yet largely preventable. Prevention of obesity is an important tactic for prevention of diabetes. Although individuals are accountable for maintaining a healthy weight, availability of healthy food, places to exercise, and a culture that supports health have an enormous influence on individual choices. The Institute of Medicine in a report, Accelerating Obesity Prevention, recently identified five strategies that prevent obesity and which they recommended be the core of community and national policy efforts. These are: Integrate physical activity every day in every way Market what matters for a healthy life Make healthy foods and beverages available everywhere Activate employers and health care professionals Strengthen schools as the heart of health Many communities and health plans focus on improving overall health through better eating, weight management, and more exercise, as a key diabetes prevention strategy. The federal Diabetes Prevention Program (DPP) evaluated a variety of programs to assess their effect on diabetes prevention. The DPP shows that prediabetes can be reversed. High-risk people and communities can take concrete action steps such as losing weight and exercising regularly to prevent diabetes, and move from prediabetes back to a normal risk level. The DPP offers many resources and recommendations to help individuals and communities take action to avoid diabetes.

From a health plan perspective, diabetes prevention activities must target both individuals and communities. People at-risk for diabetes can be identified early through “health risk assessments” that identify lifestyle factors and family heritage that may put people at higher risk for diabetes. Communities at-risk can be identified through demographic data. Working to care for high-risk individuals through care management, health promotion, and quality monitoring, health plans reduce risk of diabetes for members. Community efforts focus on helping to develop exercise, nutrition awareness, and other lifestyle improvement programs in the communities served by Medicaid health plans.

Community-Based Prevention for Diabetes MHPA member organization UnitedHealthcare announced in October that it is bringing JOIN for ME sm , a proven community-based, childhood obesity lifestyle-intervention program, to Medicaid beneficiaries who live in the New Orleans area. JOIN for ME sm is a 12-month program that helps generally healthy children who are overweight or obese reach healthier weights and reduce the risk of many related health issues. This evidence-based program emphasizes whole-family lifestyle and behavior modification delivered in 16 weekly sessions, followed by monthly maintenance sessions for up to one year. JOIN for ME sm , which engages the entire family, has demonstrated promise to become a national model to meet the critical need for effective, accessible, and affordable treatment for childhood obesity.

UnitedHealthcare and the Louisiana Alliance of Boys & Girls Clubs launched JOIN for ME sm at a Community Forum that served as a call to action for the community to join forces to fight the childhood obesity epidemic that is taking a devastating toll on families, communities, and the country. UnitedHealthcare Community Plan of Louisiana leaders noted that JOIN for ME sm will provide children with an engaging and practical solution that involves the entire family in adopting healthy eating and activity. Often, multiple members of the family lose weight by making small changes in their daily routines. The initiative will help young people and their families improve their health and quality of life.

Excerpted from: http://www.uhc.com/news_room/2012_news_release_archive/medicaid_program_fig hts_ childhood_obesity.htm Narrative | 13 While this compendium does not focus on diabetes prevention, a few of the health plan best practice examples in this publication describe plans’ community-based prevention strategies. In addition, the MHPA Center for Best Practices Treatment Adherence Best Practice Compendium includes a number of outstanding examples of health plans’ community- based prevention initiatives. The compendium is available free from the CBP’s website, www.centerforbestpractices.org. Secondary Prevention: Prevention of complications of diabetes is the key objective in secondary prevention. Effective management of diabetes essentially is designed to prevent worsening and complications of disease. Diabetes treatment goals include management of blood sugar and cardiovascular problems to prevent complications, and regular assessment for complications of diabetes.

Early identification is a crucial element of diabetes treatment. Physicians evaluate risk of diabetes in the course of care and deliver screening services. Health plans also have a role in identifying members who are high risk (through activities such as health risk assessments and health fairs) and connecting those members to physician care. High-quality diabetes care is one of the most effective strategies for preventing complications and co-morbidities. Most of the best practice examples in this compendium describe health plan initiatives to identify members with diabetes, screen them for diabetes care quality gaps, and help them to successfully manage their diabetes.

Diabetes Care Best Practices Compendium

14 | Diabetes Care Best Practices Compendium Important strategies to reduce disparities include: Ensuring that data have enough information on race, ethnicity, and other patient factors to help analyze for disparities Analyzing data to understand disparities Developing culturally competent interventions Educating staff and providers on strategies for reducing disparities Developing relationships with communities and individuals to build the trust needed for successful health partnerships, including use of peers and community health workers Helping members to address their own priorities that may influence health, such as having adequate housing or access to food Seeking external guidance or standards to evaluate the organization’s cultural competency Preventing the chronic health conditions that underlie disparities in disease prevalence and outcomes. Disparities in care and outcomes occur in racial and ethnic minorities, and also in some high-risk populations such as the homeless, people with mental illness, or people in underserved communities. Many of the best practice examples in this publication describe health plan initiatives to meet the needs of specific populations with community-based services, peers, and culturally competent services.

Medicaid Health Plan Strategies to Measure and Reduce Disparities in Diabetes Care In October 2012, the Medicaid Health Plans of America (MHPA) Center for Best Practices hosted a workshop on strategies to ensure quality care and reduce disparities in diabetes care and outcomes. The AmeriHealth Mercy Family of Companies (AMFC) outlined some of the data on disparities in the Medicaid population of Philadelphia, and discussed its strategies to reduce disparities. AMFC examined information on the Medicaid-covered population and identified 10 percent of adult members with diabetes. The majority of members with diabetes are African-American and non- Hispanic whites. Adult African-American members with diabetes were identified as more likely to have care gaps than other members. In addition, data showed high use of emergency and hospital services. Of the adult African-American members with diabetes, 25.8 percent had at least one emergency room visit and 7.5 percent had at least one inpatient admission. This information shows that more can be done to improve primary and outpatient care to reduce the need for hospital services. AMFC adopted a number of strategies to reduce identified disparities. An example of these strategies includes: Monitoring Healthcare Effectiveness Data and Information Set diabetes data by race and ethnicity to identify gaps.

Collecting individual-level race, ethnicity and language data, in addition to population-level data evaluation strategies, to improve ability to analyze and meet member needs. Providing cultural competency training to staff. As a result of adopting these strategies, AMFC’s health plans achieved the National Committee for Quality Assurance’s Multicultural Health Care Distinction. At the clinical level, AMFC interventions to reduce disparities include: Intensified approach to members with diabetes with the highest number of emergency room and inpatient events, and on multiple medications.

Implementing home-based health care services and individualized member treatment plans to build trust with members, caregivers, and providers, as well as address“non-medical”issues, such as housing, food, and the ability to adhere to treatment recommendations. Adopting a multidisciplinary team approach to helping members and overcoming barriers. Teams include physicians, behavioral health consultants and bilingual community health workers, with additional services supplemented by a home health nurse, physical therapist, dietitian and pharmacist. Case Study: Mr. S, a a boarding home resident suffering from unmanaged type 1 diabetes, had been in the hospital for a total of 101 days during 15 different visits since the beginning of 2012. Mr. S was instructed how to use a glucometer, and care managers monitored his daily insulin compliance in consultation with his primary care physician and boarding home staff. During the intake process, the care management team discovered Mr. S was living on a fixed income and made poor nutritional choices for a diabetic. He would purchase a lot of junk food at the beginning of the month, but would then eat sparingly later in the month as his funds began to run out until his next paycheck. Care managers arranged a stable source of food for Mr. S in collaboration with a community resource that will also provide nutritional education. Since entering the program at the end of June, Mr. S had only one 11-day visit to the hospital, and as of September 2012, had not returned to the hospital in 66 consecutive days.

Reducing Diabetes Disparities in People with Serious Mental Illness Value Behavioral Health of Pennsylvania (VBH-PA) implemented an intervention to increase the monitoring of Medicaid patients with serious mental illness for risk factors related to metabolic syndrome, a precursor of diabetes. The initiative targets psychiatrists prescribing Second Generation Atypical Antipsychotic Medications (SGAs). The goal is to increase screening for risk factors and improving coordination of care with primary care physicians. The program has resulted in an increasing number of psychiatrists providing the appropriate screening and referrals to primary care for their members with diabetes risk factors. Diabetes monitoring scores were 82 percent in 2012, a dramatic increase from the 11% monitoring rate when the program began in 2006. VBH-PA providers are also improving in referring at risk members to primary care. Narrative | 15

Diabetes Care Best Practices Compendium

16 | Diabetes Care Best Practices Compendium Chapter 4: Medicaid Health Plan Innovations in Improving Diabetes Care Diabetes affects both physical health and quality of life of patients. States’ Medicaid costs for diabetes are high, and the condition is challenging for physicians and other providers to identify and manage. Medicaid health plans are positioned to leverage their influence with a variety of stakeholders to improve diabetes care. Health plans have an important role in using information, patient and provider contacts, and payment incentives to improve diabetes care. Many health plans have developed care coordination programs to help members navigate their health care needs. Health plans also deliver “disease management” services that offer education, counseling, and information on treatment to members identified as having diabetes. Using data and information effectively is an important element of finding which patients have or are at risk for diabetes, and helping to close gaps in quality for these groups. Health plans use their claims (provider bills) and enrollment data systems to identify patients with diabetes and understand which services they are receiving. Health plans may also offer “risk assessment” surveys online or in person to help patients understand familial and behavioral factors that might put them at risk of diabetes. Plans use this information to develop patient and provider education and care management services that support the patients and improve care. Through use of data, health plans can also see whether patients are going to their doctor for diabetic screening tests and can alert providers and patients of needed care. For example, pharmacy claims serve as a source of information on how frequently patients are refilling medications and whether they are getting essential medications. Plans use this information to address adherence to medications, either by alerting the doctor or contacting the member directly. They may also identify safety concerns if there are duplicates or drug interactions. The best practice example from PerformRx in this publication shows how one plan uses pharmacy data to identify members who have 15 or more prescriptions and helps those members get on the right medications. Some of the approaches health plans use to improve diabetes care include: Measuring the quality of care provided to members with diabetes and developing focused efforts to increase evidence-based care. All of the health plan practices in this publication use measurement to evaluate baseline and follow up improvements in diabetes care, often using the HEDIS data set. Using care management programs to educate and support patients in making lifestyle choices that prevent and manage diabetes. Amerigroup’s AbsoluteCARE medical home initiative and the Select Health In Control program are examples of innovative care management programs. Engaging members with diabetes or those at risk for diabetes with prevention, treatment, and health education programs. For example, Delaware Physicians Care (an AETNA Health Plan) Get Control It Matters program uses innovative visual aids to show members a “Healthy Plate” and to help them understand healthy eating for diabetes prevention and control.

Connecting with members on health education through interactive websites that offer health information, health risk assessments, and games. The Buckeye Community Plan’s collaboration with AT&T on cell phone-based diabetes education shows how health plans are testing and trying out new technologies to improve health. Offering diabetes disease management directly to patients in need of additional support and education. WellCare Health Plans, Inc. is implementing the HealthConnections: Community-Based Disease Management Pilot in partnership with a Texas-based academic institution, with the goal of increasing availability of trained practitioners to improve diabetes care.

Contracting with high-quality physicians and increasing patient awareness of high-quality diabetes providers such as those recognized in diabetes care by NCQA. Partnering with physicians and other practitioners to help them understand opportunities to improve diabetes care. Volunteer State Health Plan’s program to educate physicians on comprehensive diabetes care is an example of this approach. Using incentives to encourage members to use high-quality providers and to participate in diabetes management programs. The MDwise program and the Health Partners’ You Count program both include incentives for members to engage in prevention and health improvement behaviors. Collaborating with communities and community organizations such as schools, health departments and fitness organizations to develop prevention and wellness programs. UPMC for You’s Community Health Worker Program hires members of the community to build trust and carry out a neighborhood- based health and wellness initiative.

Partnering with states to carry out payment incentive demonstration programs to reward providers for better quality care. Medicaid health plans are accountable for their diabetes care results and report HEDIS measures to show their performance. Many state Medicaid programs use health plans’ HEDIS reports to produce health plan performance report cards or other information for patients. The National Committee for Quality Assurance also reports data on diabetes care quality. The following tables show health plan performance on multiple diabetes indicators. The lower performance of Medicaid plans shows the challenges of working with a low- income, high-disparities population. But, the steadily improving performance illustrates that plans’ strategies are evolving to effectively serve the Medicaid population.

Midwest Health Plan Diabetes Control Network: Midwest Health Plan created the Diabetes Control Network to identify members with diabetes and help improve care. The Diabetes Control Network identifies members with diabetes through a comprehensive software system that supports Midwest Health Plan’s (MHP) disease management, case management, and utilization management functions. This system provides for an integrated and efficient way to identify members eligible for the program, stratify based on severity of disease, and track member interventions. Members enrolled in the Diabetes Control Network receive information and other materials focusing on the disease process and complications, medication use and adherence, nutrition, caregiver resources, self-management skills, treatment plan, lifestyle issues affecting the disease state, depression, and the importance of follow up with physicians. Members also receive reminders and incentives to complete recommended diabetes visits and testing. Primary care providers receive education and information to improve the diabetes services they provide to members. Midwest Health Plan has seen improvements in all HEDIS® measures for comprehensive diabetes care during the past three years. HbA1c testing increased from 82% to 93%; Eye exams increased from 60% to 62%; LDL screening from 79% to 80%, and monitoring for nephropathy increased from 87% to 98%. Narrative | 17

Diabetes Care Best Practices Compendium

18 | Diabetes Care Best Practices Compendium C H R O N I C C O N D I T I O N M A N A G E M E N T LDL CHOLESTEROL SCREENING COMMERCIAL MEDICAID MEDICARE YEAR HMO PPO HMO HMO PPO 2011 85.3 81.2 75.0 88.3 86.7 2010 85.6 79.9 74.7 87.8 86.3 2009 85.0 78.6 74.2 87.3 85.5 2008 84.8 74.7 74.1 86.3 82.3 2007 83.9 72.7 70.8 85.7 80.0 2006 83.3 67.4 71.1 84.8 79.4 2005 92.3 87.0 80.6 93.3 87.1 2004 91.0 – 79.6 93.5 – 2003 88.4 – 75.9 91.1 – 2002 85.1 – 70.8 87.9 – 2001 81.4 – 66.5 85.7 – 2000 76.5 – 1999 69.0 – LDL CHOLESTEROL CONTROL (

20 | Diabetes Care Best Practices Compendium Chapter 5: Diabetes Care Best Practices Submissions Best Practices | 21 Buckeye Community Health Plan (Centene® Corporation) and AT&T/WellDoc Buckeye Community Health Plan and AT&T mHealth Solutions Presents DiabetesManager® description: This targeted pilot program initiative offered a group of high-risk diabetes patients (cared for by Centene’s Buckeye Community Health Plan) access to AT&T mHealth Solutions Presents DiabetesManager®, the enterprise mHealth solution from AT&T and WellDoc®. The FDA-cleared application is a self-management tool that enables patients to manage their diabetes. Members can track food consumption and blood sugar levels by logging their activity via a secure mobile application software. A group of 59 program participants reduced their average hemoglobin A1c (HbA1c) results from 9.4% to 8.7% after using the application. A decrease in hospital (-55%) and emergency room (-16%) utilization was also observed in the program’s participants.

According to 2010 data from the CDC, it is estimated that 10.1% of Ohio adults have been diagnosed with diabetes. In 2000, it was 6.5%. If current trends continue in Ohio as they have nationally, one in three Ohioans will develop diabetes during their lifetime. In adults, type 2 diabetes accounts for about 90 to 95% of all diagnosed diabetes cases. Inactive lifestyles, obesity, and smoking are all contributing factors that may increase the risk of developing type 2 diabetes. A 2007 American Diabetes Association report indicated that the annual costs associated with diabetes in Ohio were $5.9 billion, including $3.9 billion in medical expenditures and $2 billion in reduced state productivity and premature mortality. The total charges of hospital discharges in 2007 with a primary diagnosis of diabetes were approximately $442 million.

The WellDoc® DiabetesManager System was designed to address the health and cost issues associated with diabetes in Ohio. The System is indicated for use in adults — aged 21 years and older — who have type 2 diabetes. It is designed to provide secure capture, storage, and transmission of blood glucose data as well as information to aid in the support of diabetes self-management. key objectives: Enhance the patient experience of care (including quality, access, and reliability) by leveraging mobile technology to improve diabetic member outcomes.

Improve quality of care in a specific clinical area (e.g. prenatal care, diabetes, asthma, etc.). Make a positive impact in the care of individuals struggling to manage their diabetes by extending care beyond the physician’s office. actions taken: With the help of case managers and staff at Buckeye Community Health Plan, we identified a pool of high risk type II diabetic members who were potential candidates for the program — with the final pool of 200 type II diabetics that was also 50% minority. Candidates were identified through a coordinated member enrollment initiative — sign-up events, invitation letters, member training, etc. Health plan staff (i.e., case managers, coordinators, and other support staff) were trained on the phone application and portal entry system. Work flows were then developed from a clinical, member support, and registration perspective. Finally, metrics were selected to measure outcomes — for example, hemoglobin A1c tests, member participation and engagement, emergency department and hospital admissions, etc.

22 | Diabetes Care Best Practices Compendium Best Practices | 23 Once program participants were enrolled, they were trained on how to use the phone and the application for entering blood glucose levels and other clinical information — carbohydrate consumption, activity, medications, etc. Participants were required to make an average of seven blood glucose entries per week. Health plan case managers and staff monitored activity and followed up as needed to address engagement issues and out of range blood sugar results entered by members.

Of the 200 potential candidates for the program, 145 completed the pilot on the AT&T mHealth Solutions Presents DiabetesManager® application. Of those individuals completing the program, we had 59 members with verifiable hemoglobin A1c(HbA1c) readings prior to the start of the pilot. outcomes: A. For the group of 59 members with verifiable hemoglobin A1c (HbA1c) results prior to the start of the program, we showed an average decrease in HbA1c from 9.4% to 8.7% after 1-5 months of using the mobile application.

The hemoglobin A1c test is an important blood test used to determine how well a person’s diabetes is being controlled. For people without diabetes, the normal hemoglobin A1c range is between 4% and 5.6%. In uncontrolled diabetes, sugar builds up in the blood and combines with hemoglobin. Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes, and levels of 6.5% or higher indicate diabetes. Because studies have repeatedly shown that out-of-control diabetes results in complications from the disease, the goal for people with diabetes is a hemoglobin A1c less than 7%. The higher the hemoglobin A1c, the higher the risks of developing complications related to diabetes.

B. Comparisons were made between the program participants and a similar population (high-risk, type II diabetics, etc.) for hospital and emergency room utilization 90 days prior to program registration compared to 90 days after registration. The results (shown below) reflect a 55% decrease in hospital utilization and a decrease of 16% in emergency room utilization for program participants compared to members who did not participate. C. We also measured member engagement and utilization throughout the initiative as number of blood sugar entries through the mobile application. Prior to implementation, the decision was made to require participants to record a minimum of seven entries per week (one entry per day average). As shown below, members maintained an average level of five to six entries per week throughout the initiative. geographic location: Buckeye Community Health Members in the Southwest, Northwest, Northeast and East Central areas of Ohio (see service map below): contact: Artie Paniagua MBA, BSN, RN Director Clinical Policy and Support, Centene Corporation (314) 725-4706 ext. 25038; apaniagua@centene.com Program Participation Status Member Count Pre 90 MM Post 90 MM Program Participation Status ER Visits Hospital Visits No 677 1,762 1,641 No 0.363 0.106 Yes 145 421 421 Yes 0.044 0.001 Grand Total 822 2,182 2,062 Grand Total 0.143 0.282 P‐value < .05 is considered to be statistically significant. Program Participation Status Pre 90 Hospital Visits Post 90 Hospital Visits % Change Pre 90 Per 1,000 Post 90 Per 1,000 No 139 149 7% 315.6 363.2 Yes 56 25 ‐55% 532.5 237.6 Grand Total 195 174 ‐11% 357.4 337.6 Program Participation Status Pre 90 ER Visits Post 90 ER Visits % Change Pre 90 Per 1,000 Post 90 Per 1,000 No 484 442 ‐9% 1,098.9 1,077.5 Yes 145 122 ‐16% 1,378.9 1,159.3 Grand Total 629 564 ‐10% 1,152.8 1,094.2 P‐Values

24 | Diabetes Care Best Practices Compendium UPMC for You Community Health Worker Program description: The Community Health Worker Program is a collaborative effort between UPMC for You and various community centers located in areas with a high concentration of African Americans. These communities have health care disparities. The program is a neighborhood-based health and wellness initiative. The objectives of the program are to develop relationships with key stakeholders in those communities through the use of Community Health Workers. Through those relationships, we will engage not only our members, but residents of the community, in chronic condition education programs, lifestyle management, and to connect them to needed health care and social resources. Engagement of Medicaid members in health or care management programs through telephonic methods can be successful only to a point. The current rate of reaching our members hovers around 35 to 40%. Poor addresses and phone numbers, and lack of relationships with the health care community make it difficult to reach a large portion of our members. Community-based programs, placed in the communities where the members reside, offered through peers, in a culturally sensitive manner can greatly improve the engagement of members; improve access to services, quality of care, appropriate utilization of services, and satisfaction with the experience of care.

The four communities identified for the Community Health Worker Program have almost 18,000 members. Of those, 70% are African American. The UPMC for You rate of African Americans over the age of 18 with diabetes is 10.39%. By comparison, the rate of diabetes in our Caucasian members over the age of 18 is 7.94%. The high rate of diabetes and other chronic conditions with corresponding gaps in care has been identified as an opportunity. Our experience with programs such as the Patient Centered Medical Home and the community- based care teams, which are based on face-to-face interactions with members, have a higher engagement rate and can be more successful in helping members to access health care services and manage their care. The implementation of the community heath workers will assist us in reaching and engaging more members who have chronic conditions, in addition to providing support to non-UPMC for You community residents. key objectives: Improve the health of the population Enhance the patient experience of care (including quality, access and reliability) Control or reduce the per capita cost of care or increase efficiency Reduce disparities in care of racial and ethnic minorities actions taken: UPMC for You has provided the funding to hire four Community Health Workers in May 2012. These individuals were hired in conjunction with the community centers and are residents of the community. They have begun to talk with community stakeholders, identified the health care and other social support services available, and are gathering information on the unique needs of those communities. UPMC for You partnered with UPMC Family Medicine to develop a training program for the Community Health Workers. A UPMC physician provided key elements of that training. The Community Health Workers devote 40% of their time to activities directed by the centers and 60% on health plan directed activities. The Community Health Workers are meeting with individuals in the communities with the goals to: Identify needed health care or social services and assist residents in accessing those services Provide culturally appropriate health care related information Give informal counseling and guidance on heath behaviors and self-management of chronic conditions Identify health and wellness programs that can benefit the resident Advocate for the individual Coordinate the promotion of health and wellness programs For UPMC for You members, provide referrals to health plan care management programs and coordinate accessing services for those members UPMC’s Community Health Workers (CHW) have received specific training on diabetes through a program developed by the University of Pittsburgh’s Department of Family Medicine. Their role in supporting those with diabetes is to act as an advocate, liaison and role model. The CHWs have completed an inventory of the health and wellness services that are available within the communities they are serving and at the community center they are located. They will help link a person with diabetes to the services that they may need, including those lifestyle classes offered at the community centers, such as exercise. We are currently in the process of working on scheduling the Stanford chronic education classes in each of the four community centers. They CHWs will help to organize and promote the event. Those with diabetes will be invited to attend these classes. outcomes: The evaluation for this program is not set until 2013. geographic location: The program has been implemented in Pittsburgh, Pennsylvania in four communities through the Hosanna House, Inc., Bidwell Presbyterian Church and Manchester Youth Development Center, Hill House, Association and the Kingsley Association.

contact: Debra Smyers Senior Director Program Development, UPMC for You (412) 454-7755; smyersd@upmc.edu Midwest Health Plan Diabetes Control Network description: Midwest Health Plan created the Diabetes Control Network to identify members with diabetes and help improve care. The Diabetes Control Network identifies members with diabetes through a comprehensive software system that supports Midwest Health Plan’s (MHP) disease management, case management, and utilization management functions. This system provides for an integrated and efficient way to identify members eligible for the program, stratify based on severity of disease, and track member interventions. Members enrolled in the Diabetes Control Network receive information and other materials focusing on the disease process and complications, medication use & adherence, nutrition, caregiver resources, self-management skills, treatment plan, lifestyle issues affecting the disease state, depression, and the importance of follow up with physicians. Members also receive reminders and incentives to complete recommended diabetes visits and testing. Primary care providers receive education and information to improve the diabetes services they provide to members. Midwest Health Plan has seen improvements in all HEDIS® measures for comprehensive diabetes care during the past three years. HbA1c testing increased from 82% to 93%; Eye exams increased from 60% to 62%; LDL screening from 79% to 80%, and monitoring for nephropathy increased from 87% to 98%.

Midwest Health Plan continues to implement the Diabetes Control Network program to address the following issues: According to the 2011 Michigan Diabetes Burden Report, Diabetes affects 25.8 million Americans (8.3% of the population) and an estimated 1.65 million Michigan citizens. Diabetes costs the United States $174 billion annually and over $9 billion per year in Michigan. Total medical costs for Midwest Health Plan’s members with diabetes were $14,492,819 and prescription costs were $6,773,941 for a total cost of $21,266,760.

Michigan’s 2011 Behavioral Risk Factor Survey reports that diabetes was the seventh leading cause of death in 2010. In 2011, an estimated 10% of Michigan adults reported being told by a doctor that they had diabetes. The prevalence of diabetes increases with age and decreases with increasing household income level. Disabled adults (18.4%) were more likely to have been diagnosed than non-disabled adults (6.6%). In 2011, 72% of members with diabetes were in the aged, blind and disabled (ABAD) Medicaid group. Best Practices | 25

26 | Diabetes Care Best Practices Compendium key objectives: Improve the health of the diabetic population Enhance the patient experience of care (including quality, access and reliability) Improve quality of care in a specific clinical area (medication adherence, patient education, lifestyle changes, specialty care, etc) actions taken: The initiatives of the Diabetes Control Network include: Members enrolled in the Diabetes Control Network receive information and other materials quarterly which focus on disease process and complications, medication use & adherence, nutrition, caregiver resources, self-management skills, treatment plan, lifestyle issues affecting the disease state, depression, and the importance of follow up with physicians.

Community health fairs are held where diabetes services are performed such as dilated eye exams, blood pressures, and podiatrist foot exams. Educational materials and preventive health guidelines are distributed to members to assist in self- management. A Health Risk Assessment (HRA) is sent to all new health plan members upon enrollment. Members are eligible for a $5 gift card incentive for the return of an HRA. Basic educational material is sent when the form is returned with a positive response on the diabetes question and members are also enrolled in the disease management program.

Incentive reminder letters are sent to members who are due for the following annual diabetes screening tests: Lipid screening Microalbuminuria Dilated eye exam Hemoglobin A1C Members can receive a $10 gift card per completed test. Members must return the form via fax/mail with their Primary Care Physician’s (PCP) signature to receive the gift card. Opportunity Reports are available to physicians on the MHP website. The reports allow providers to access administrative/clinical data through a secure website. These reports allow providers to view services completed and services due for their patients.

PCP’s are notified about our free glucometer program via the Provider Newsletter and MHP website. Members are informed via the member newsletter and DM mailings. Members are also informed about the program when they are in communication with a DM Nurse who will order a meter for the member if needed. A diabetes satisfaction survey is sent to members enrolled in the Diabetes Control Network program annually. The survey is used to obtain comments and feedback from the members and also to review any complaints the member may have regarding the program.

Members with diabetes who had 3 or more hospital admissions during the preceding three months are automatically referred to Case Management. Health Services nurses then follow-up with members for evaluation and possible entry into case management. Members are also stratified based on other comorbidities including hypertension and hyperlipidemia. Members are tracked and follow up is done through additional interventions. outcomes: MHP measures the effectiveness and outcomes of our programs through annual HEDIS® indicators and results. Processes are then refined based on these outcomes. Annually, MHP performs program-specific chart audits to ascertain the effectiveness of the interventions using HEDIS® indicators. The HEDIS® indicators used are: HbA1c testing; LDL-screening; eye exam (retinal) performed; kidney disease (nephropathy) monitored.

MHP provides provider-specific HEDIS® performance feedback annually. HEDIS® measures are used to assess the effectiveness of health management programs, so this intervention provides information to PCP’s on the extent to which members are receiving care in compliance with the clinical guidelines. A senior member of the Quality Management Department confers with physicians regarding their out of compliance members, engages in instructional dialogue, and provides patient-specific compliance tools for follow up and documentation.

The ongoing interventions of the diabetes disease management program have demonstrated an improvement in the delivery of services and better patient & physician awareness. This is evidenced by the HEDIS® results below: geographic location: Southeast Michigan contact: Andrea Fogarty Director, Health Management, Midwest Health Plan (313) 586-6071; afogarty@midwesthealthplan.com 3 Briefly identify specific outcomes / data related to the initiative identified in question 3. Use speci where possible. (Limit to one to two paragraphs) MHP measures the effectiveness and outcomes of our programs through annual HEDIS ® indicator results. Processes are then refined based on these outcomes. Annually, MHP performs program-s chart audits to ascertain the effectiveness of the interventions using HEDIS ® indicators. The HEDI indicators used are: HbA1c testing; LDL-screening; eye exam (retinal) performed; kidney disease (nephropathy) monitored.

MHP provides provider-specific HEDIS ® performance feedback annually. HEDIS ® measures are assess the effectiveness of health management programs, so this intervention provides information PCP’s on the extent to which members are receiving care in compliance with the clinical guidelin senior member of the Quality Management Department confers with physicians regarding their ou compliance members, engages in instructional dialogue, and provides patient-specific compliance for follow up and documentation.

The ongoing interventions of the diabetes disease management program have demonstrated an improvement in the delivery of services and better patient & physician awareness. This is evidenc the HEDIS ® results below: HEDIS ® Measure Comprehensive Diabetes Care (CDC) 2010 2011 2012 *HbA1c testing 82.1% 88.5% 92.7% *Eye Exam 59.7% 61.3% 61.5% *LDL‐C Screening 79.2% 83.4% 84.7% *Monitoring for Nephropathy 86.5% 92.3% 97.8% 8. Geographic Location Southeast Michigan 9. Contact Information (to be listed in the publication) Contact Name: Andrea Fogarty Best Practices | 27

28 | Diabetes Care Best Practices Compendium Best Practices | 29 NurseWise®/Nurse Response™ (A Centene® Company) Diabetes Education for Serious Mental Illness (SMI) description: NurseWise of Arizona has developed a diabetes education program for persons with Serious Mental Illness which is delivered in conjunction with a community behavioral health services provider. Through the combined physical and behavioral health program, NurseWise is able to provide integrated care services for people with SMI, and to enhance screening and treatment for diabetes. As part of the program, the community provider identifies and invites members to participate in a weekly support group that addresses both mental and physical health, as well as social issues. A registered nurse with both diabetes education and psychiatric nursing experience leads the group and tailors materials and interventions to the unique needs of this population. Members meet weekly, keep their own workbooks, and the group activities are documented in their medical record. Members learn how to manage their diabetes and how to communicate their needs and progress to their behavioral and medical providers.

key objectives: To increase appropriate treatment for serious co-morbidities associated with SMI To improve long-term medication adherence To use and measure the effectiveness of appropriate patient education To improve coordination of care for persons with SMI when services are carved out actions taken: Key initiatives taken to meet the program objectives are: Development of referral and program admission criteria for the diabetes education group in coordination with the behavioral health agency. Engaging persons with SMI in self-management of their diabetes through structured group meetings, activities and nutritional education.

Integration of behavioral and physical care within a single point of care. The SMI participants are able to attend diabetes education at the same clinic setting where they receive psychosocial therapies and medication management. Diabetes group notes including topics discussed, interventions planned and participant engagement, are documented in the participants’ medical record, and available for review by the community agency’s treatment providers. Our registered nurse educator develops the diabetes education program activities for the group and tailors modules according to participants’ functional level.

outcomes: Nurse Response is able to demonstrate positive outcomes as a result of the Diabetes Education program. Our initial measure is SMI client participation in the group education sessions. For the past 12 months (January to December 2012), the program has seen an increase in attendance, beginning the year with four participants at the monthly meetings and ending the year with a total of six participants. While the participants vary from month to month, attendance is averaging five participants per meeting. Within the next program year, in collaboration with the community behavioral health agency, we are targeting collection of HbA1C measures of participants during program participation provided by behavioral health agency records. The agency prescriber may order labs directly or obtain results from the PCP with a medical release of information from the participant. Analysis of the participants’ HbA1c levels over time will allow us to tie our intervention to positive clinical outcomes.

geographic location: Case study program was conducted in Pinal County, Arizona. contact: Valerie Lauerman Director, Call Center Operations, NurseWise/Nurse Response (480) 317-2141 ext 26601; vlauerman@centene.com Amerigroup Maryland Diabetes Total Wellness Initiative: Learning to Live and Thrive with Diabetes description: From 2011 to the present, Amerigroup has developed a collaborative relationship with community-based organizations and network providers to improve disparities in health outcomes for diabetic members. This relationship has resulted in the sharing of opportunity lists for care gaps for network providers, reaching out by telephone to address barriers and coordinating medical appointments for members, one stop shopping clinic days and collaborating with the American Diabetes Association. As a result of these interventions, Amerigroup has demonstrated a significant improvement in Healthcare Effectiveness Data and Information Set (HEDIS) measures for the following: Hemoglobin A1c (HbA1c) testing, Dialated Retinopathy Exam, HBA1C control, LDL-C screening and Attention for Nephropathy.

Amerigroup Maryland has approximately 3,000 adult patients with diabetes and at least 2,000 members with pre-diabetes. Almost one-half (1,329) of the Amerigroup population with diabetes reside in the Baltimore area. The majority of Amerigroup members with diabetes, as with many low-income adults with the condition, often do not receive the routine care they need to help prevent complications. This is due in part to limited access to primary care and a lack of awareness of the relationship between preventive care and good health. The Amerigroup Quality Indicators for Effectiveness of Care demonstrated the majority of adult members with diabetes had not received screening for HbA1c, nephropathy or elevated blood lipids in the past year. key objectives: The objectives of this program were: To improve access to routine screening for HbA1c, elevated blood lipids and nephropathy for the largest population of adult diabetic members in Baltimore City Increase access to care and address barriers though program incentives and transportation Provide a one stop shopping experience where members can receive testing, education, and support in one location Collaborate with the American Diabetes Association to a provide community education program on diabetes self-care Improve the health of the diabetic population Enhance the patient experience of care (including quality, access and reliability) Improve quality of care in a specific clinical area including medication adherence, patient education, lifestyle changes, and self-care.

Reduce disparities in care of racial and ethnic minorities actions taken: On the provider level, Amerigroup has instituted financial incentives and resource tools such as patient opportunity lists to promote routine care for diabetic patients including HbA1c and blood lipid screening. Amerigroup Maryland also collaborated with its eye care vendor, Block Vision, to coordinate provider incentives, telephonic outreach and mailings for dilated retinopathy screenings for members. Amerigroup also collaborated with the American Diabetes Association to conduct a six-week diabetes education program with screenings at Lexington Market in Baltimore City, near where the majority of affected members live. Members received incentives to stay motivated with the program, including transportation to the classes and a Target gift card for attendance and participating in the health screenings.

30 | Diabetes Care Best Practices Compendium Best Practices | 31 outcomes: In one year from 2010-2011, Amerigroup demonstrated a significant increase in percentage points for HEDIS measures for Effectiveness of Care for Diabetic members including: HbA1c testing from 73.95 in 2010 to 72.2 HbA1c control from 50.47 to 50.72 Dilated Retinopathy Screening from 51.4 to 62.26 LDL Screening from 69.3 to 71.63 LDLC Control from 33.26 to 38.22 Attention for Nephropathy from 74.42 to 78.85. geographic location: Amerigroup has made this program available to members in Baltimore City, Maryland. contact: Dianne Houston-Crockett Associate Vice President, Health Promotion, Amerigroup Maryland (410) 981-4026; dianne.houston-crockett@amerigroup.com PerformRx, AmeriHealth Mercy Health Plan (AMHP), and Keystone Mercy Health Plan (KMHP) Drug Therapy Management (DTM) Program for Diabetics Who Are High Utilizers description: PerformRx, in partnership with AmeriHealth Mercy Health Plan (AMHP) and Keystone Mercy Health Plan (KMHP), created the Drug Therapy Management (DTM) Program for Diabetics Who Are High Utilizers to reduce the incidence of medication-related problems (MRPs), improve the delivery of care, and control medical costs. This URAC-accredited DTM program is a collaborative effort integrating pharmacist-based interventions and care management, targeting diabetic members consuming 15 or more medications. As the pharmacy benefits manager, a PerformRx pharmacist reviews member medication regimens together with medical claims and may contact the prescriber and/or the patient, via the care manager, to suggest one or more DTM interventions (e.g., a change in medication). Care managers from KMHP/AMHP assist with the execution and follow-up of pharmacist-recommended, patient-targeted interventions. Health plan members participating in this DTM program demonstrated improved outcomes in the number of inpatient admissions and emergency room (ER) utilization over a one-year period compared to health plan members in the control group; the most impressive being KMHP’s reduction in inpatient admissions (76.4%; P=0.0002). While not statistically significant, pharmacy costs did increase in all groups as expected; however, total costs (medical + pharmacy) demonstrated a statistically significant decrease in the DTM group compared to the control group (47.8% for KMHP, P=0.0039; and 50.7% for AMHP, P=0.0497; Figure 2).

Patients with chronic conditions, including diabetes, are often managed with polypharmacy, i.e., the use of multiple medications to treat primary and secondary comorbid conditions. According to a 2006 estimate, nearly one third of adults consume five or more different medications each week. Problems with polypharmacy arise when a greater number of medications than clinically warranted are prescribed. Polypharmacy increases the risk of MRPs and non- adherence, negatively impacting health and driving up medical costs. About 1.5 million preventable MRPs occur each year, resulting in an estimated $3.5 billion annually in additional medical costs to treat the injuries alone (excluding lost wages and productivity).1 These MRPs account for as many as 28% of all emergency department visits, of which as many as 24% resulted in a hospital admission.2 DTM services are an emerging component of the managed care approach to optimizing patient care. Our DTM program uses both: 1) a data-driven approach to identify the diabetic population and address actual and potential MRPs and 2) an integrated approach towards pharmacy and care management to achieve optimum quality of care, thereby reducing costs.

key objectives: Improve the health of the diabetic population Improve the health of a specific subpopulation, e.g. people taking antipsychotic medications Control or reduce the per capita cost of care or increase efficiency actions taken: Pharmacists reviewed complete member profiles, including pharmacy and medical data, to identify and address evidence-based interventions including, but not limited to: Medication Non-Adherence Additional Therapy Needed Lack of Medication Monitoring/Self- Monitoring Therapeutic Substitution Drug-Drug Interaction Drug-Disease Interaction Duplicate Therapy Inappropriate Dosage Change in Therapy _ _ 1 Aspden P, Wolcott JA, Bootman JL, Cronenwett LR (eds), Preventing Medication Errors: Quality Chasm Series. Institute of Medicine of the National Academies. The National Academies Press, Washington DC. July 20, 2006. http://www.iom.edu/ Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx 2 Patel P, Zed JP. Drug-Related Visits to the Emergency Department: How Big is the Problem? Pharmacotherapy, 2002; 22(7).

http://www.medscape.com/viewarticle/439814 3 MEASURE VBP Neutral VBP Incentive NCQA 50th NCQA 75th NCQA 90th DHMH 2010 MCOAvg 2010 Results 2011 Results Variance (2010-2011) VBP NCQA ^ DHMH ^ Effectiveness of Care Comprehensive Diabetes Care HbA1c testing - - 81.10 86.43 90.27 77.1 73.95 76.2 2.25 - X X HbA1c control - - 56.93 66.31 72.41 54.5 50.47 50.72 0.25 - X X DRE 66 74 54.01 63.69 70.11 66.6 51.4 62.26 10.86 X X X LDL screening - - 75.36 80.15 84.07 74.9 69.3 71.63 2.33 - X X LDC control - - 33.76 40.92 45.54 38 33.26 38.22 4.96 - - X Attention for Nephropathy - - 77.78 82.73 86.25 79.2 74.42 78.85 4.43 - X X In one year, from 2010-11, Amerigroup demonstrated a significant increase in percentage points for HEDIS measures for Effectiveness of Care for Diabetic members including:  HbA1c testing from 73.95 to 72.2  HbA1c control from 50.47 to 50.72  Dilated Retinopathy screening from 51.4 to 62.26  LDL screening from 69.3 to 71.63  LDLC control from33.26 to 38.22  Attention for nephropathy from 74.42 to 78.85 8. Geographic Location Baltimore City, Maryland 9. Contact Information (to be listed in the publication) Contact Name: Dianne Houston-Crockett Title: Associate Vice President, Health Promotion Company: Amerigroup Maryland Phone Number: (410) 981-4026 E-mail: Dianne.Houston-Crockett@amerigroup.com Name of person completing form (if it differs from contact person above): Kate Massey Phone Number: (202) 218-4901 E-mail: Kate.Massey@amerigroup.com

32 | Diabetes Care Best Practices Compendium Prescriber targeted interventions were addressed directly with the prescriber by the pharmacist, while patient interventions were forwarded to care management. Care managed members were counseled by their respective care managers thereby leveraging existing care manager-patient relationships, streamlining patient contact efforts and resulting in a seamless managed care experience from the patient perspective. Non-care managed members were counseled by urgent response care managers expanding the resources available to these members to both DTM and care management services. At any time, a pharmacist was available to assist in the patient counseling and communication. An intervention may have been flagged as either urgent or non-urgent in nature, may have required prescriber and/ or member outreach, and may have required care management services/follow-up. The prescriber or member was free to accept or reject the suggested intervention. The pharmacist performed a follow-up 20 days after care manager referral, and 90 days after provider outreach and used claims data to determine the subsequent course of action. When a recommendation to add a medication was accepted by the prescriber, the pharmacist tasked the care manager to outreach to the member to assess member satisfaction with the new medication regimen. outcomes: Health plan members with diabetes targeted by this program are at-risk for medication related problems (MRPs) related to taking fifteen or more prescribed medications, possessing an average seven-fold greater disease burden (as measured by DxCG prospective risk scores) than the plan average. The DTM study groups (690 from KMHP and 264 from AMHP) were reviewed for DTM services between 11/1/2010–7/31/2011, followed by a 3-month run-out period to allow the recommendations to go into effect. The control groups (600 from KMHP and 210 from AMHP) were not reviewed for DTM services. Overall, the acceptance rates were relatively higher as dual interventions involving both the care manager and pharmacist outreach, but relatively lower for changes-of-therapy interventions. KMHP participants in the DTM program demonstrated a statistically significant reduction in inpatient admissions compared to the control group (76.4% difference-in-differences, DID; P=0.0002), whereas AMHP participants in the DTM program demonstrated a statistically non-significant reduction (35.9% DID; P=0.4148; Figure 1). Comparative outcomes for ER utilization in the DTM versus control groups were less dramatic and not statistically significant for either plan. While DTM-based interventions resulted in statistically non-significant increases in pharmacy-related costs (per member per month, PMPM) when comparing the DTM study and control groups (9.8% DID for KMHP, P=0.8780; and 16.9% DID for AMHP, P=0.4151), the medical cost savings borne by the health plan were substantially greater, resulting in a statistically significant total cost savings (pharmacy + medical; PMPM) when comparing the DTM study and control groups (47.8% DID for KMHP, P=0.0039; and 50.7% DID for AMHP, P=0.0497; Figure 2). geographic location: Members of KMHP for the DTM program were distributed throughout the plan’s Pennsylvania service area, which includes Philadelphia, Delaware, Bucks, Montgomery, and Chester counties. Members of AMHP for the DTM program were distributed throughout its 15-county service area in Central and Northeastern Pennsylvania.

contact: Lauren Brophy, PharmD, FAHM Director, Drug Therapy and Formulary Management, PerformRx (215) 937-4135; lauren.brophy@performrx.com 2 Program Profile for MHPA’s Diabetes Care Best Practice Compendium Please complete this questionnaire and return it to Liza Greenberg@mhpa.org on or before Friday, November 16, 2012. By completing and returning this form, you agree that MHPA may publish a case study developed from your responses. MHPA may also use submissions in other topical best practices compendia produced by the MHPA Center for Best Practices during the course of 2013. MHPA may edit the descriptions. Members will have the opportunity to review, edit and approve prior to the Compendium publication. Submitters may include high-res graphics (photos, charts and graphs) to run along with their submission. Figure 1: Inpatient Admissions in DTM Study versus Control Group * statistically significant (P

34 | Diabetes Care Best Practices Compendium Best Practices | 35 DELAWARE PHYSICIANS CARE, an AETNA Health Plan Get Control It Matters description: Improve the Delaware Physicians Care (DPCI) diabetic member with diabetes’s HgA1c and LDL levels by launching two self-management member focused programs along with provider education and outreach. Diabetes- Get Control, It Matters Plate Program and Diabetes Self-Management Program (DSMP) teach coping skills while supporting a holistic approach to managing a chronic condition. Collaborative project designed to compound the ongoing efforts/intervention: The Get Control- It Matters (GCIM) program is offered to all people with diabetes make healthy choices at each meal, every day. The Diabetes Self-Management Program (DSMP) is offered to those members with diabetes that are at “high risk”. This six week interactive program gives the DSMP graduate the tools to self-manage their diabetes through journaling and making smart choices about how they will live with this chronic disease.

The third key component to this program is using dedicated resources for provider outreach using a HEDIS- based primary care provider profiling program that includes a toolkit for providers to help them to provide care to our members. The HEDIS based Comprehensive Diabetes Care Work Group (CDC) reports to the DPCI Quality Management / Utilization Management Committee. In 2010, the CDC work group systematically approached their task to improve the health of the diabetic members. The DPCI CDC Work Group created a Project Charter which outlines the expected benefits of this project, defines the actual problem, and follows the goal statement which applies specific, measurable, attainable relevant and time bound parameters for HEDIS based provider outreach. In June of 2011, diabetes was categorized as the seventh leading cause of death in the United States and affects 25.8 million people which are 8.3% of the U.S. population. There are 18.8 million people with a diagnosis of diabetes. An estimated 7.0 million people have not been diagnosed, yet. Self-management education or training is a key step in improving health outcomes and quality of life. Successful programs focus on self-care behaviors that include healthy eating choice, staying active, and monitoring blood sugars along with cholesterol levels. It is a collaborative process in which diabetes educators help people with or at risk for diabetes gain the knowledge and problem-solving and coping skills needed to successfully self-manage the disease and its related conditions.1 In Delaware, diabetes has risen, following the nation’s trend, from 4.3 percent in 1995 to 9 percent in 2007. 2 Delaware’s diabetes prevalence rate is slightly higher than that of the nation by 58,000. At the national level, approximately 13 percent of African Americans and 8 percent of Caucasians have diabetes. In Delaware, this same health disparity exists, but to a lesser extent: roughly 11 percent of African American adults and 9 percent of Caucasian adults have diabetes.

Obesity is an especially strong risk factor for the development of type 2 diabetes. An estimated 9,297 have pre-diabetes (see Appendix 1: Glossary of Terms)1 Engaging in preventive health strategies markedly improves the health of people with diabetes can reduce diabetic health complications by achieving optimal HgA1c levels, cholesterol profiles and reducing blood lipid levels. 3 Less than half of people in Delaware attend educational classes for improving their Diabetes. More than 60 percent were had their lab tests related to diabetes in the past year even though the 90% of these patients are visiting their doctor once a year. “Promoting standards of diabetes care across the state will help ensure that all Delawareans with the disease receive recommended preventive health care.” 2 key objectives: Improve the health of the population Control or reduce the per capita cost of care or increase efficiency Improve quality of care in a specific clinical area e.g. prenatal care, diabetes, asthma, etc. actions taken: The Get Control it Matters (GCIM) was designed for DPCI members living with diabetes ages 18-75. The goal was to influence the diabetes member in making healthier choices when eating. The objective is to influence members to make healthier choices by limiting the intake of simple carbohydrates, high fat foods, and providing on-going support to influence lifestyle change. This may assist DPCI members in controlling their blood glucose levels which was facilitated by utilizing the Idaho Health Plate Program. The Idaho Health Plate program, also known as the Health Diabetes Plate Program is a program that emphasizes the foods that people living with diabetes should eat. The Healthy Diabetes Plate takes the five food groups and helps you visually create healthy and tasty breakfasts, lunches, and dinners. You don’t need to measure or weigh your foods or buy special food products. All you need is a 9-inch plate for your vegetables, starches, and protein foods, plus a small bowl and/or glass for your fruit and dairy products.

In November and December of 2010 the first Get Control – It Matters Plate Packet was mailed to 2703 DPCI members and available in both English and Spanish. The Get Control - It Matters Plate Packet includes: 2-sided placement that has breakfast displayed on one side & lunch/dinner on the other. A 9-inch plate. “How-to” guide (Plate Method for Meal Planning guide). Keep your Diabetes under Control booklet. Purpose of Get Control - It Matters Plate Packet: A visual guide for healthy eating.

Helps with portion control. Each meal is designed to give you a total of 1400 calories a day. This will help your blood sugar stay steady throughout the day. How to use the placemat: Before eating, place the 9-inch plate over the breakfast or lunch/dinner sides. Your plate portions should look exactly like the picture portions. Ask yourself if you have the right foods. Do you have protein, vegetable, starch and fruit? Measure food on your plate to match the serving size. Food on your plate should be no higher than one-inch high.

The method of measuring success will be looking for lab improvements for DPCI members in the 2012 NCQA HEDIS Comprehensive Diabetes Laboratory Measures. The unanswered question is could behavior modification interventions provide members an approach to improve their quality of life by improving the compliance of HbA1c and LDL-C levels. The first measurement was only looking at the actual testing of HgA1c and LDL. After reviewing the data presented by the Data Repository team, the measurements were expanded and the interventions refocused to look at improving the HgA1c and LDL levels.

_ _ 1 J Am Diet Assoc. 1998 Oct; 98(10):1155-8. The Plate Model: a visual method of teaching meal planning. DAIS Project Group. Diabetes Atherosclerosis Intervention Study. Camelon KM, Hådell K, Jämsén PT, Ketonen KJ, Kohtamäki HM, Mäkimatilla S, Törmälä ML, Valve RH. 2 www.ncbi.nlm.nih.gov/pmc/articles/pmc1832142/#B4#B4 3 http://www.changingdiabetes-us.com/ManagingDiabetes/HealthyEating/Overcomin gBarriers/

36 | Diabetes Care Best Practices Compendium Best Practices | 37 WellCare Health Plans, Inc. HealthConnections: Community-Based Disease Management Pilot - Diabetes description: In a unique private/public/academic venture, WellCare granted Texas A&M Health Science Center to establish partnership with community and clinical leaders in the Houston-Galveston area to help implement and disseminate evidence-based self-management programs. Based on its experience with implementing and evaluating the Stanford’s Chronic Disease/Diabetes Self-Management Program, the Program on Healthy Aging at the School of Rural Public Health is helping the Houston Consortium build capacity for the coordinated delivery of self- management program for improving senior health.

Diabetes has become an increasingly common chronic disease that remains one of the most serious health problems in Texas. Approximately two million adult Texans have diagnosed diabetes, including over 27 percent of those over the age of 65, and it is the sixth leading cause of death in the state. Self-management of this condition is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions. These Diabetes Self-Management Programs (DSMP) aim to achieve optimal health status and a better quality of life, while also reducing the need for costly healthcare. The goal of this initiative is to empower aging Texans to take control of their health and to become more self-sufficient in dealing with their medical needs.

key objectives: Improve the health of the population Control or reduce the per capita cost of care or increase efficiency Improve quality of care in a specific clinical area e.g. prenatal care, diabetes, asthma, etc. actions taken: The grant-funded pilot designed to offer additional workshops to increase overall participation; expand the number of delivery site; increase the number of master trainers and lay leaders; expand the points of evaluation to include direct participant feedback and improve tracking and reporting. Program success is defined as: Holding at least 40 Workshops and serving at least 400 older adults (age 60 and older). Engaging at least 20 delivery sites to offer CDSMPs, with diabetes self-management being a key offering. Building a training infrastructure of four master trainers and 30 lay leaders. Establishing mechanism for participant feedback like documenting how they are better managing their chronic illness.

Ensuring program oversight and compliance – class size, completion rates, leader input and so on. outcomes: The program launched on April 1st and the first results for reported in July for the first quarter (April 1 – July 31). The following are the first quarter results: Hosted Houston Consortium meeting on May 2, 2012 to solicit community partners to become a delivery site. Hosted formal program launch on June 13, 2012. Conduct three (of 40) workshops reaching 22 (of 400) older adults with a 98% completion rate. Contracted with three (of 20) delivery sites.

Launched youtubeTM testimonial and survey processes on June 13, 2012 through which two success stories/ vignettes have been identified. Launched oversight and compliance process and reporting. geographic location: The pilot is currently administered in Houston-Galveston area as well as Brazos Valley. Based on early results, WellCare plans to expand the program and started discussions with Texas A&M Health Science Center to determine the best approach for expansion. contact: Pamme Taylor Vice President, Advocacy & Community Based Programs, WellCare Health Plans, Inc. (813) 317-1204; pamme.taylor@wellcare.com A DPCI Diabetes Care Text Messaging pre-and post -survey was completed for 60 members to gather information regarding concerns around barriers the member experiences in controlling their diabetes. A post survey which contained the same questions after the intervention mailed to members was completed to the same high risk numerator for which 48 were able to complete the post survey. Finally, a high risk sub group had been formed and charged with not only maintaining the momentum of the GCIM initiative, but also with enhancing further services and exploring opportunities to expand the initiative.

outcomes: geographic location: The intervention is taking place in the three counties in Delaware; Kent, New Castle and Sussex. contact: Alex Marino, MBA, Six Sigma Black Belt Healthcare QM Project Manager, Delaware Physicians Care, Incorporated, an Aetna Health Plan (302) 894-6655; marinoD2@AETNA.com

38 | Diabetes Care Best Practices Compendium Best Practices | 39 Amerigroup Healthy Families Program description: To help stem the growing obesity epidemic and prevent the early onset of diabetes, Amerigroup created the Healthy Families Program, which is designed to help our members between the ages of seven and 13 and their families manage their weight by establishing healthy eating habits and activity levels. As part of the Healthy Families Program, Amerigroup initiates outbound calls to parents to partner in identifying potentially overweight preteen children. Children who qualify receive fitness and healthy behavior coaching, including connection to community and online resources.

The Healthy Families Program was created to reduce childhood obesity, which can have both immediate and long-term effects on health and well-being including diabetes, cardiovascular disease, increased risk for bone and joint problems, sleep apnea, and social and psychological problems, such as stigmatization and poor self-esteem. Through this unique program, Amerigroup addresses a health issue using many tools — health coaching, social media, care coordination, and community resources — in an effort to fundamentally influence health behaviors.

key objectives: Improve the health of the diabetic population Control or reduce the per capita cost of care or increase efficiency Improve quality of care in a specific clinical area (medication adherence, patient education, lifestyle changes, specialty care, etc) actions taken: To enroll members, screening calls are made to potential participants who are identified by health condition, family history, and/or weight status and their interest is assessed. Once identified as an interested member, referrals are made to Amerigroup case managers who reach out to confirm participation. Enrolled members benefit from a four-pronged strategy over a six-month period that includes the following: Education and Support: Amerigroup provides recurring and consistent outreach to participants who receive biweekly calls to establish and monitor goal setting. Health coaches also provide assistance in overcoming personal barriers to success.

Provider Collaborations: Coordination with participants’ primary care physician is a critical component of the program. Physicians receive notification of their patient’s enrollment in the Healthy Families Program, status updates throughout the duration of their enrollment and clinical practice guidelines for obesity so that they will be able to reinforce healthy behaviors during patient visits. Specialized Web Tools: Amerigroup supplements health coaching with web tools including Nourish Interactive, a nationally recognized website. This online tool is a one-stop resource for fun nutrition games for children and interactive nutrition tools and tips for parents to promote healthy living for the whole family.

Community Resources: Amerigroup also connects participants to the community by facilitating referrals to community-based programs such as those that focus on nutritional education, cooking classes, or school-based health services (dependent by market). outcomes: When case managers first engage participants, they establish a baseline of eating habits and physical activity such as the amount of soda and water consumed on a daily basis, and the amount of time spent in front of a computer and/or television. In partnership with program participants, case managers work to establish reasonable goals that will result in an improvement in health outcomes. Program results have demonstrated that the program is successful in influencing healthy behaviors as noted in the attached table. geographic location: The Healthy Families Program is operational in several Amerigroup markets, including Florida, Louisiana, Nevada and Washington.

contact: Christie Aloneftis Associate Vice President, Health Care Management Services, Amerigroup (757) 473-2737, ext 32151; christie.aloneftis@amerigroup.com

40 | Diabetes Care Best Practices Compendium Best Practices | 41 Select Health of South Carolina In Control Diabetes Care Management description: South Carolina ranks fifth highest in the nation for percentage of population with diabetes, according to the South Carolina Department of Health and Environment Control. Select Health offers First Choice, the state’s first and largest Medicaid health plan, and is a wholly-owned member of the AmeriHealth Mercy Family of Companies (AMFC). actions taken: First Choice plan members with diabetes were stratified into low-risk and high-risk groups, based on resource utilization rates (ER visits, medications, inpatient stays) and predictive modeling scores. Both the low-risk and high-risk members received educational mailings throughout the year. These mailings included a welcome packet of comprehensive diabetic information for newly diagnosed plan members, quarterly printed material informing members about necessary health management topics and periodic member newsletter articles relating to seasonal diabetic topics of interest. High-risk members were further screened by a nurse case manager to determine the candidates most appropriate for case management intervention. The case management team works together to meet the member’s needs at all levels in a proactive manner that is designed to prevent adverse outcomes and avoidable episodes of care. To this end, a nurse collaborated with the member or caregiver and the primary care provider, specialist or other providers to develop an appropriate individualized plan of care to match the member’s needs. High-risk members engaged in disease case management received focused educational mailings when appropriate based on the diabetic care plan. Mailings focused on healthier eating habits, promoting physical activity, smoking cessation, medication compliance, screening tests, home monitoring glucose testing and managing stress.

In 2012, First Choice developed a Rapid Response department to assist with members’ urgent needs. Members of the Rapid Response team are care connectors and registered nurses. This team assists members with getting their medications and makes sure members’ urgent hospital discharge needs are met. These employees are available to members Monday through Friday, 8:00 a.m. to 5:00 p.m. Select Health associates also participated in enterprise-wide workgroups through AMFC to improve outreach and education for members with diabetes. In addition to increasing outreach and offering case management to these members, the plan’s medical director outreached to providers to provide education about member benefits. Members admitted to the hospital with a diabetes diagnosis were offered home health visits on discharge to reconcile medications and provide diabetic education. The case managers were also provided additional education on cultural themes and barriers related to diabetes care in the underserved. Effective April 1, 2012, First Choice began providing behavioral health benefits to all of its plan members. This benefit helps treat underlying depression that can often go along with having a chronic medical condition, like diabetes.

The 2012 Healthcare Effectiveness Data and Information Set (HEDIS®) results showed a decrease in members with diabetes who received dilated eye exams. In response to this decrease, Select Health mailed a vision directory to all members with diabetes. The goal of this mailing was to educate members about the importance and need for eye exams and provide a resource list of in-network providers available to them in their area. outcomes: Select Health achieved an improvement in 2012 HEDIS® results (measurement year 2011) for the following diabetes measurements from the previous measurement year: Members with poor HbA1c control (>9) decreased to 44.97% from 47.13% (decrease denotes better performance).

Members with an LDL C screening (

42 | Diabetes Care Best Practices Compendium Best Practices | 43 key objectives: Improve the health of the population Improve delivery of benefits Improve quality of care in a specific clinical area e.g. prenatal care, diabetes, asthma, etc. actions taken: MDwise contracted with a vendor to build a system to process and tabulate member points based on eligibility, claims received and other pertinent data feeds. Members can view their points, how they earned those points, and redeem them for a gift card. MDwise offers a variety of gift card choices, values equal to $10, $30 and $50, depending on the number of points the member has earned and wants to redeem. At least annually, MDwise sends out a specific mailing to each member household about the Rewards program and have made improvements to that message over time. MDwise has gradually increased the ways in which we communicate this program to members in other member materials and notices that are distributed. We have developed informational tools for provider offices, so that providers can encourage wellness behaviors through this program with their MDwise patients. Our Customer Service and Case Management staff uses the program as a tool to encourage members to complete Health Risk Screening surveys and to comply with needed screenings such as LDL, mammograms and cervical cancer, as well as prenatal and postpartum appointments. Changes to the program were informed by a member focus group where additional ideas on how to make the program more understandable and accessible were gained.

outcomes: As of December 31, 2011, 197,724 members had sufficient points to be eligible for a redemption. 760 members successfully redeemed their points for a gift card in 2011 (the start-up year), peaking at 173 redemptions in the month of December. 61% of those members redeemed at the first reward tier of $10. 40% chose a Subway gift card. 34% of those that redeemed a gift card did so at the $30 level. A steady upward trend has been noted in the number of redemptions over time. Following a May 2012 mailing to every member household specifically about the program, the number of member redemptions was eight (8) times what was experienced in previous months. Prior to that mailing, the average number of redemptions was 113 per month. Following the mailing, that number jumped to 906 in May of 2012 and 457 in June of 2012. The MDwise. org/rewards web page also showed a 559% increase in hits after the postcard was mailed. We are continuing to monitor trends in order to understand ongoing redemption rates and relationships to marketing. geographic location: Available to MDwise membership throughout the State of Indiana contact: Jamie Bruce, MBA, CHC Chief Marketing and Business Development Officer, MDwise (317) 822-7118; jbruce@mdwise.org DC Chartered Health Plan, Inc. The mHealth Program description: The Chartered mHealth program focuses on high engagement interventions to increase the self-efficacy of members to manage their chronic conditions. There were 40 non-compliant members diagnosed with Type 2 Diabetes selected for the pilot program. All of the members were provided free, cell phones to facilitate receiving diabetes management specific text messages as one of the interventions. In addition, the members were included in a cooking class and a movement session to educate them on simple activities they can implement to help them live a healthy life with diabetes. Tracking the success of traditional disease management programs is challenging with transitional populations. Members are not typically enrolled with the plan or in a program for a significant amount of time in order to track trends or consistent results. Since HEDIS measures are collected and analyzed annually, they are an ideal measure for this initiative. Historically, achieving increases in the HEDIS percentiles require significant labor and monetary resources. Hence, identifying new ways to make even incremental changes is important. Our focus is to create sustained changes in a member’s beliefs and behaviors about how they manage their health while being diagnosed with a chronic condition and, assist them to take responsibility for doing so. key objectives: Engage members in managing their chronic health condition and improve self-efficacy Utilize text messages to deliver health-related messages Bring health to the member in their community Decrease ER visits as a result of members having controlled HbA1c and blood sugar readings actions taken: The key initiatives used in this program are text messages, care management support and, community-based events focused on health promotion. The interventions focus on maintaining health and, thereby avoiding a preventable exacerbation of their condition which could result in an emergency room visit or other acute utilization. We leveraged a user- friendly, HIPAA compliant platform called, Suniyea to send single or multiple SMS messages to members. This gave us the ability to pre-schedule messages, send two-way messaging and customize messages to different members.

Health-related text messages serve several functions. They are a reminder to members that they are part of a health program and, have the support of the Chartered case management team to maintain their health. Studies have shown improvement with participants who have health coaches or known support available. In addition, the messages are educational thereby reinforcing self-management knowledge. The community-based events such as the cooking class and the movement/fitness session emphasized simple activities that members could easily implement in their home and repeat on a regular basis without being intimidated by complex ingredients for cooking, or costly gym equipment for exercising. Taking a mind/ body approach, the next intervention will emphasize developing healthy thinking habits to strengthen their fortitude during challenging times. These include how to stop self-sabotaging behavior, limit negative thinking and leverage positive events to bolster the bad times. These types of interventions have proven successful in other studies to alleviate depression.

outcomes: The specific HEDIS measures used for compliance are as follows: Eye Exam, HbA1c Poor Control, HbA1c Testing, LDL-C Screening (CDC) and Medical Attention for Nephropathy. In March, at the start of the program each member was non-compliant on at least one measure. In July, 26 members were compliant with one or more measures than they were at the start of the program. A self-efficacy survey was conducted via telephone to gather baseline data at the beginning of the pilot. The scores of all 40 members fell in the low range of self-efficacy. Chartered will re-administer the survey to determine if any improvement has been achieved. The learning from this pilot will support replication of these interventions for a group of members diagnosed with hypertension.

44 | Diabetes Care Best Practices Compendium Value Behavioral Health of PA (a ValueOptions® Company) Monitoring for Risk of Metabolic Syndrome in Persons Prescribed Second Generation Atypical Antipsychotic Medications description: Value Behavioral Health of Pennsylvania (VBH-PA) has implemented an intervention to increase the monitoring of its Medicaid membership with serious mental illness who are prescribed Second Generation Atypical Antipsychotic Medications (SGAs). SGAs are used to treat serious mental illness, and come with an increase risk of developing metabolic syndrome or diabetes induced by weight gain. Prescribing and monitoring practices have been studied from 2006 to present in ten large mental health outpatient provider practices, with the goal of increasing evidence based monitoring for side effects of SGAs. The initiative, begun in 2006, addresses psychiatrists prescribing SGAs and seeks to increase the coordination of care with primary care physicians. Annual provider feedback and self-monitoring tools have been distributed by the VBH-PA Quality Department. The quality of monitoring and coordination of clinical services with primary care providers has increased steadily during the intervention period.

key objectives: Increasing appropriate treatment for serious co-morbidities associated with SMI Improving coordination of care for SMI when services are carved out actions taken: VBH-PA developed an intervention to improve care for patients prescribed one of the following SGAs: Abilify, Clozaril, Zyprexa, Seroquel, Risperdal, Risperdal Consta, Geodon, or Invega Sustenna. The company developed a screening tool based on the recommendations of the Consensus Statement on Antipsychotic Drugs and Obesity and Diabetes, a white paper published by the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity. 1 In 2006, the Consensus Statement was sent to the providers with a request for a sample of charts in order to carry out a baseline measurement Following the baseline measurement, VBH-PA developed and sent to providers a monitoring tool they could use or adapt to aid them in increasing their risk monitoring practices. The screening tool outlines clinical monitoring of 16 risk factors indicated in early identification and management of metabolic syndrome or diabetes. The Quality Management Department audits a sample of charts from each provider annually and returns feedback through aggregate and provider specific results.

Providers scoring less than 80% are asked to develop corrective action plans to increase monitoring practices. Figure 1 - Annual Rate of Monitoring for Metabolic Syndrome 11% 22% 48% 54% 68% 80% 82% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 2006 2007 2008 2009 2010 2011 2012 _ _ 1 Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes: American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity, DIABETES CARE, Volume 27, Number 2, February 2004. geographic location: All the members live in Washington, DC with the majority of the residing in Wards 4 and 7.

contact: Karen M. Dale, RN, MSN Executive Vice President, Healthcare Management, DC Chartered Health Plan, Inc. (202) 326-8741; kdale@chartered-health.com Other Project Team members that can answer questions regarding program are: Samuel Batts, Mark Fracasso, Cheree Ingram, Paul Kennedy, Lavdena Orr, Sumeet Vashista, Sumeet Seth and Parminder Sethi. www.chartered-health.com; (202) 408-4720 Best Practices | 45

46 | Diabetes Care Best Practices Compendium Best Practices | 47 outcomes: Table 1 outlines the annual monitoring rate of each indicator. All 16 indicators have shown improvement since the baseline measurement in 2006; 75 percent of the indicators have shown improvement over the last year. 4 Table 1 outlines the annual monitoring rate of each indicator. All 16 indicators showed some improvement. The increases in total percentages over the past year ranged from five percent to 100 percent. Table 1 - Percentage of Monitoring Documentation RISK FACTOR MONITORED 2006 2007 2008 2009 2010 2011 2012 Personal history of diabetes 19% 25% 59% 60% 70% 79% 88%  Family history of diabetes 4% 11% 24% 45% 69% 77% 80%  Personal history of obesity 18% 32% 55% 51% 69% 80% 88%  Family history of obesity 0% 9% 24% 43% 64% 77% 73%  Personal history of dyslipidemia 21% 25% 62% 55% 69% 82% 88%  Family history of dyslipidemia 0% 10% 24% 42% 64% 77% 80%  Personal history of hypertension 24% 35% 60% 55% 70% 77% 88%  Family history of hypertension 0% 11% 26% 45% 67% 79% 80%  Personal history of cardiovascular disease 13% 24% 59% 53% 69% 81% 88%  Family history of cardiovascular disease 1% 14% 24% 42% 72% 77% 80%  Weight recorded 21% 61% 78% 72% 85% 90% 93%  Height recorded 3% 29% 48% 58% 61% 74% 78%  Waist circumference recorded 0% 24% 33% 25% 25% 50% 48%  Blood pressure recorded 18% 50% 59% 60% 77% 92% 85%  Fasting plasma glucose ordered 13% 61% 71% 79% 82% 86% 85%  Fasting lipid profile ordered 12% 51% 69% 75% 47% 84% 85%  In 2009, VBH-PA began tracking the number of individuals identified as having, or at risk of developing, metabolic syndrome, the rate that providers referred to supportive services, and the number of individuals who followed up with these services. In 2012, 26 individuals were identified as either having, or at risk for developing, metabolic syndrome. Twenty three of these individuals were given a referral to a supportive service. All of these were referred to the individual’s primary care physician (PCP). Documentation indicated that 13 of these individuals followed up with their PCP. Table 2 compares these rates over time.

Table 2 - Rate of Integrating Care 2009 2010 2011 2012 At risk or diagnosed with metabolic syndrome 21% 80% 59% 43% Referred to PCP 27% 28% 63% 88% Followed up with PCP 59% 63% 55% 68% In 2009, VBH-PA began tracking the number of individuals identified as having, or at risk of developing, metabolic syndrome, the rate that providers referred to supportive services, and the number of individuals who followed up with these services. In 2012, 26 individuals were identified as either having, or at risk for developing, metabolic syndrome. Twenty three of these individuals were given a referral to a supportive service. All of these were referred to the individual’s primary care physician (PCP). Documentation indicated that 13 of these individuals followed up with their PCP. Table 2 compares these rates over time.

Table 2 - Rate of Integrating Care 2009 2010 2011 2012 At risk or diagnosed with metabolic syndrome 21% 80% 59% 43% Referred to PCP 27% 28% 63% 88% Followed up with PCP 59% 63% 55% 68% The sixth annual measure of provider monitoring practices for metabolic syndrome shows a slight increase from last year’s rate. Recording of waist circumference, blood pressure, and fasting glucose declined in 2012. However, gains were made in monitoring personal and family histories and lipid profiles. Additionally, 80 percent of the providers audited are now utilizing a template or incorporating monitoring prompts on existing forms. VBH-PA providers are also demonstrating increased commitment to integrated care, as individuals with elevated risk factors are referred to their PCPs more frequently than in previous years. geographic location: Nine counties in Southwestern Pennsylvania contact: Leigh Gardner Director of Quality Management, VBH-PA (724) 744-6310; leigh.gardner@valueoptions.com 6 Figure 2 - Provider Scores Based on Use of Monitoring Tools Discussion The sixth annual measure of provider monitoring practices for metabolic syndrome shows a slight increase from last year’s rate. Recording of waist circumference, blood pressure, and fasting glucose declined in 2012. However, gains were made in monitoring personal and family histories and lipid profiles. Additionally, 80 percent of the providers audited are now utilizing a template or incorporating monitoring prompts on existing forms. VBH-PA providers are also demonstrating increased commitment to integrated care, as individuals with elevated risk factors are referred to their PCPs more frequently than in previous years.

7. Organization Information Geographic location of case study program: Nine counties in Southwestern Pennsylvania Name of person completing form: Leigh Gardner Title: Director of Quality Management Department: Quality Management E-mail leigh.gardner@valueoptions.com Phone: (724)744-6310 79% 100% 94% 94% 94% 100% 100% 100% 44% 25% 0% 20% 40% 60% 80% 100% 1 2 3 4 5 6 7 8 9 10 tool no tool

48 | Diabetes Care Best Practices Compendium Best Practices | 49 Centene® Corporation Nurtur’s Diabetes Program description: Health Coaches who are Certified Diabetes Educators teach participants and/or their parent or caregiver how to control blood glucose levels, comply with recommended screenings, promote healthy eating habits, and encourage regular physical activity. Our diabetes program provides health coaching and support delivered through telephonic coaching and educational materials. We address life barriers, improve self- management skills, and promote adherence to prescribed treatment guidelines in order to minimize the development and/or progression of diabetic complications. actions taken: Members are identified for enrollment based on medical and pharmacy claims data. Members may also be referred to the program by a health plan physician, case manager or self-referral. An introductory mailing is sent to targeted members and health plan physicians announcing the program and informing members or caregivers they will receive a phone call. Telephonic outreach begins seven days after the introductory mailing is sent and several attempts to contact a member by telephone are made. Members who do not respond to telephonic outreach are sent a postcard encouraging enrollment. Once contact is made, the program is explained to members, eligibility is confirmed and a health assessment is initiated to identify clinical risk, education needs, and assign the member to a Certified Diabetes Educator. The Health Coach will complete an assessment and develop an individualized care plan based on the member’s or caregiver’s knowledge of their condition, lifestyle behaviors and readiness to change. Internal clinical guidelines are developed from nationally-recognized, evidence-based guidelines published by the American Diabetes Association.

The Health Coach uses a variety of creative tools to ensure the members are getting the educational materials in a format that fits them best. The program uses MP3 players for those with literacy issues. For members without safe, reliable phone access, a pre- programmed cell phone is given to them loaded with our Diabetes Management book (which received the Merit Award for the 2011 Web Health Awards) as well as other podcasts on wellness and managing their disease. The phones also include videos on diabetes and insulin as well as a link to the American Diabetes Association. A trial of members with smart phones is currently underway in one of our health plans. These phones contain applications in general categories: calorie counting, meditation music, medicine reminder and sugar tracking. outcomes: Our review consisted of 6256 members from six health plans enrolled in our diabetes health coaching program as compared to a matched control group. The average time in health coaching was 244 days. Participants in the program had a 26% decrease in diabetes- related admissions per 1000 claimant years (p

50 | Diabetes Care Best Practices Compendium Best Practices | 51 outcomes: Results suggest member adherence in the intervention groups increased due to the outreach effort. The on-site visit method had a statistically higher percentage of patient’s becoming compliant within three months of the intervention (10%) compared to the control group. This program increased member’s compliance for diabetic HbA1c testing by increasing VSHP’s provider outreach and education on optimal diabetes care. The on-site method of provider education had better outcomes compared to the mailing method for reaching providers. Due to the increased compliance and positive outcomes this intervention is ongoing. The CDC focus used for identification and stratification of the target population varies each year based on member compliance rates. However, the targeted providers are furnished member compliance detail for all the CDC gaps in care measures.

geographic location: State of Tennessee contact: Lisa Eaves, RN, BS, CPHQ Clinical Consultant, Volunteer State Health Plan (423) 535-3542; lisa_eaves@vshptn.com Converting Rate for the Intervention and Control Groups Health Partners of Philadelphia, Inc. YOU Count description: The Health Partners’ “YOU Count” program is aimed at providing essential health screenings, such as A1c, LDL cholesterol, blood pressure and body mass index to members with diabetes, high blood pressure, high cholesterol and related conditions. Held three-to-four times a year, it offers incentives for members to attend and complete all testing, with additional incentives to members who achieve healthier A1c and LDL scores. The overall goal is to empower our members to achieve self management of their conditions and improve their health outcomes.

YOU Count was initiated to help us reach our adult members with the aforementioned health conditions. After receiving a disease-specific diagnosis, we found that a high percentage of members experienced difficulty accessing their PCP or specialist for a variety of reasons. By offering the event in the community, we make it more convenient for members to get screened. Other issues included members not being aware of the health services available through their benefit and the importance of health screenings, while others were reluctant to schedule time to visit their doctor, or were afraid of blood testing. This was especially true for our diabetic members, who in greater numbers were not following up with their PCP. We later discovered this was due to their confusing finger stick with a blood draw. Members are given a copy of their results and are encouraged to visit their doctors to discuss with them their most recent results. Members who do not achieve healthier scores for both A1c and LDL are also invited back to be re- tested and receive health tips, with the goal of helping them improve their scores. Members are also offered case management through the Health Partners Clinical Outreach Department. The case managers educate, follow up and coordinate the members care with their PCP.

key objectives: Improve the health of the population Improve quality of care in a specific clinical area e.g. prenatal care, diabetes, asthma, etc. Enhance the patient experience of care (including quality, access and reliability) actions taken: Our Community Relations and Healthcare Management teams worked together to identify members with high blood pressure, high cholesterol, diabetes, pre-diabetes and/or obesity. Once they were identified, we collaborated with community partners to select a location convenient to members and accessible by public transportation to host the event. The targeted member population was sent an eye-catching invitation to let them know about the screening event and the incentives available to them if they choose to participate. Initially, the program was only focused on screenings to increase members’ awareness of their health issues. The program later evolved into an outcomes-based initiative to encourage members to participate in these vital screenings and work together with their healthcare provider to improve their scores. Members who do not achieve healthier scores for both A1c and LDL are invited back to be re-tested and to receive health tips, with the goal of helping them improve their scores. outcomes: Health Partners measures the effectiveness of YOU Count by not only the overall specific disease condition HEDIS measures, but the member-specific compliance to appropriate HEDIS measures. Since 2010, 900 members have participated in the program with 83 percent meeting their A1c goal and 55 percent meeting their LDL goal.

geographic location: YOU Count is available to our members in Philadelphia and surrounding counties. contact: Carol Smolij Vice President of Regulatory & Clinical Operations, Health Partners of Philadelphia, Inc. (215) 991-4251; csmolij@healthpart.com 16.1% 20.8% 13.2% 10.7% 10.0% 15.0% 20.0% 25.0% onverting Rate % Converting Rate for the Intervention and Control Groups 5.4% * 10.1% * 2.5% 0.0% 5.0% Intervention Overall Intervention - On-site Visit Intervention - Mailing Control Group Co

52 | Diabetes Care Best Practices Compendium RESOURCes | 53 Chapter 6: Diabetes Resources Patient-Focused Sites American Diabetes Association (ADA) www.diabetes.org The ADA offers a comprehensive website that includes diabetes facts, self-management information, meal planning, research information and other information targeting patients in simple language. The ADA “Living With Diabetes” website includes information to help patients at various points of living with diabetes, from those newly diagnosed to those with complications. http://www.diabetes.org/living-with-diabetes/ _ _ American Association of Diabetes Educators (AADE) http://diabetesselfcare.org/find The AADE “Take Charge of Your Diabetes” website offers self-management information for patients including diet, exercise and medication management information. It also includes information for health care professionals, including materials to support educational programs for patients. AADE also accredits diabetes education programs to validate that they deliver evidence based diabetes education according to AADE’s standards of care. Health plans can search for accredited providers in their networks.

_ _ National Diabetes Information Clearinghouse http://diabetes.niddk.nih.gov/ This resource from the federal government’s National Institutes for Health includes comprehensive information on diabetes, including statistics, treatment information, links to research programs, and other materials. The Clearinghouse also has diabetes information in Spanish: http://diabetes.niddk.nih.gov/spanish/index.aspx and a page, “Financial Help for Diabetes Care” http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/ _ _ National Diabetes Education Program (publications for patients) http://ndep.nih.gov/diabetes/pubs/catalog.htm The National Diabetes Education Program (NDEP) offers a wide array of resources for patients, including brochures, videos, podcasts and other education materials. All materials are in multiple languages and formats, and patients can search for exactly what they are looking for. NDEP’s “Your Game Plan to Prevent Diabetes” is a key resource for patients. http://ndep.nih.gov/diabetes/pubs/GP_Booklet.pdf _ _ Health Information for People with Special Information Needs - American Academy of Family Physicians – Health Literacy Resources www.aafp.org/online/en/home/clinical/publichealth/ptpops/healthliteracyreso urces.html Physician Information Sites American Diabetes Association - Diabetes Pro http://professional.diabetes.org/ In addition to patient-directed information, the ADA maintains a website for health care professionals that includes clinical practice recommendations, headlines from new research findings, and materials professionals can share with their patients. The “ADA Living with Diabetes Toolkit” is an important resource to guide physician discussions with patients.

American Diabetes Association Standards of Care 2012 http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=84160 ADA Slide set of 2012 Diabetes Treatment Recommendations http://professional.diabetes.org/ImageBank.aspx _ _ American College of Physicians – Diabetes Portal http://diabetes.acponline.org/ The American College of Physicians (ACP) Diabetes Portal a free ACP Diabetes Care Guide for physicians. This is a practice guide and self-assessment program for all members of the care team involved in caring for patients with diabetes. (registration required) _ _ American Association of Clinical Endocrinologists www.aace.com/publications/guidelines The American Association of Clinical Endocrinologists (AACE) offers an array of clinical practice guidelines, including guidelines for developing a comprehensive diabetes treatment care plan. _ _ National Committee for Quality Assurance –Diabetes Recognition Program http://www.ncqa.org/tabid/139/Default.aspx NCQA’s Diabetes Recognition program is a voluntary self-measurement program by which physicians evaluate their adherence to diabetes standards of care. The program has 10 measures that address important elements of diabetes treatment, including blood sugar, blood pressure, and cholesterol control, along with eye and kidney assessments and counseling on smoking cessation.

54 | Diabetes Care Best Practices Compendium Resources for Reducing Diabetes Disparities Organizing Communities to Improve Health communities creating health environments A national initiative to help communities of color implement policies for healthier, safer communities. www.ccheonline.org Diabetes and Health Information for Racial and Ethnic Minority Groups american diabetes association Live Empowered/African American Programs http://www.diabetes.org/in-my-community/programs/african-american-programs/ in my community - native american programs http://www.diabetes.org/in-my-community/programs/native-american-programs/ in my community - latino programs http://www.diabetes.org/in-my-community/programs/latino-programs/ niddk latino resources http://diabetes.niddk.nih.gov/dm/pubs/hispanicamerican/ niddk african-american resources http://diabetes.niddk.nih.gov/dm/pubs/africanamerican/ Data to Address Disparities centers for disease control - diabetes and prediabetes http://apps.nccd.cdc.gov/DDTSTRS/default.aspx national diabetes information clearinghouse http://diabetes.niddk.nih.gov/dm/pubs/statistics/ national health plan collaborative to reduce disparities http://www.nationalhealthplancollaborative.org/index.html national minority quality forum http://www.nmqf.org/ race and ethnicity in data collection http://www.ahrq.gov/research/iomracereport/reldata1.htm RESOURCes | 55 Other Helpful Resources Community and Worksite Health Improvement CDC Healthier Worksite INITIATIVE http://www.cdc.gov/nccdphp/dnpa/hwi/toolkits/index.htm COMMUNITY COMMONS A website that includes data and information to help communities assess their health status and make changes to improve health.

http://www.communitycommons.org/ diabetes at work http://www.diabetesatwork.org/ minority diabetes coalition http://www.nmqf.org/minority-diabetes-coalition/ national diabetes education program http://ndep.nih.gov/ STATE DIABETES PREVENTION AND CONTROL PROGRAMS - cENTERS FOR DISEASE CONTROL http://www.cdc.gov/diabetes/states/ Coordinated Care PaTIENT-CENTERED PRIMARY CARE COLLABORATIVE: “THE MEDICAL HOME AND DIABETES CARE” http://www.pcpcc.net/files/diabetes_guide_2011.pdf Diabetes Prevention aMERICAN ASSOCIATION OF FAMILY PHYSICIANS Physician resources for diabets prevention. http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=7 CDC NATIONAL DIABETES PREVENTION PROGRAM http://www.cdc.gov/diabetes/prevention/ DIABETES PREVENTION PROGRAM (research results) http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/

56 | Diabetes Care Best Practices Compendium RESOURces | 57 Obesity CENTERS FOR DISEASE CONTROL OBESITY PREVENTION http://www.cdc.gov/obesity/data/adult.html/ iNSTITUTE OF MEDICINE ACCELERATING PROGRESS IN OBESITY PREVENTION http://www.iom.edu/Reports/2012/Accelerating-Progress-in-Obesity-Prevention .aspx WEIGHT OF THE NATION Data and links to community initiatives to prevent obesity. http://theweightofthenation.hbo.com/ NOTES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

58 | Diabetes Care Best Practices Compendium NOTES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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