Medicaid Health Plans of America
Center for Best Practices

       Diabetes Care
Best Practices Compendium

table of contents                |   3

Table of Contents

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
4   |   Diabetes Care Best Practices Compendium                                                                                                                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.       About MHPA Center for Best Practices
                          Any errors in this compendium are the responsibility of the author.
                                                                                                    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
                             Supported by an educational grant from Roche Diagnostics               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
                                               Copyright © 2013                                     knowledge transfer to disseminate innovative
                            Medicaid Health Plans of America Center for Best Practices              solutions to caring for underserved populations.

                                          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
6   |   Diabetes Care Best Practices Compendium                                                                                                            welcome      |   7

                                                  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.

                                                                                                     Michelle M. Martin
                                                                                                     MHPA Center for Best Practices
8   |    Diabetes Care Best Practices Compendium                                                                                                                                                                                Narrative   |   9

                                                                                                                                                                               to both lifestyle and medication recommendations remains
        Chapter 1: About Diabetes                                                                                                                                              low. The statistics outlined below demonstrate how diabetes
                                                                                                                                                                               contribute to poor health outcomes. For example, according
                                                                                                                                                                               to the National Institutes of Health:
        Diabetes is a critical health issue for the United States and for Medicaid health plans. An estimated 26 million,                                                                Adults with diabetes have heart disease death rates
        or approximately 8% of U.S. residents have diabetes. That number is higher among racial and ethnic minority                                                                      about two to four times higher than adults without
        populations; almost 13% of adult African-Americans and 12% of Hispanic populations have been diagnosed with                                                                      diabetes.
        diabetes. Diabetes is also more prevalent in the elderly and low income populations — meaning that it is an                                                                      The risk for stroke is two to four times higher among
        important issue for health plans serving these Medicaid beneficiaries.                                                                                                           people with diabetes.
        Also of great concern is the potential for future cases of type 2 diabetes: 35% of adults over 20 have signs and                                                                 Up to 67% of diabetics have blood pressure greater
        symptoms of prediabetes. Prediabetes may progress to type 2 diabetes unless people adopt healthy behaviors. It                                                                   than or equal to 140/90 mmHg or use prescription
        is often reversible through changes in diet and exercise resulting in weight loss.                                                                                               medications for hypertension.
                                                                                                                                                                                         Diabetes is the leading cause of new cases of
        Obesity is a key driver of diabetes. With a third of the population now clinically obese, the toll of diabetes may                                                               blindness among adults ages 20–74 years.
        continue to rise. Some racial or ethnic minority groups are at particularly high risk for the development of diabetes                                                            Diabetes is the leading cause of kidney failure, with
        related to obesity. Preventing obesity as a nation, and treating weight problems for individuals with diabetes                                                                   almost 50,000 new cases each year.
        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             Standards of Care for Diabetes                           60-70% of people with diabetes have mild to severe
                                                                                                                                                                                         neuropathy (nerve damage), and 60% of non-
        policies that will create a healthy environment that prevents obesity.
                                                                                                                                                                                         traumatic amputations are in people with diabetes. 1
                                                                                                                                Type 2 diabetes is a complex and
                                                                                                                                progressive condition. Treatment requires
                                                                                                                                control of the diabetes-specific symptoms
        What is Diabetes?                                                                                                       – high or low blood sugar – and also careful   How Can Diabetes be Treated
        Type 1 diabetes stems from the body’s inability to make insulin which helps process glucose (sugar) for energy.         attention to preventing and treating           More Effectively?
        Type 1 represents a small percentage (5-10%) of all persons with diabetes. Type 2 diabetes is the most common           complications.
        form of diabetes. Type 2 diabetes is the result of both reduced insulin secretion and reduced insulin effectiveness,                                                   The goal of treatment for type 2 diabetes is maintaining near
        conditions known as insulin resistance. Because insulin is necessary to metabolize glucose in the body, absent or       Each year additional research results in new   normal or target range blood sugar levels and preventing
        insufficient insulin results in high blood sugar (hyperglycemia).                                                       recommendations for diabetes treatment.        complications. Successful management includes both
                                                                                                                                The American Diabetes Association has          medical interventions and patient adoption of a healthy
                                                                                    Type 2 diabetes can sometimes be            taken the lead in convening physicians         lifestyle with nutritious eating and regular exercise. High
                                                                                    controlled with diet and exercise,          and other diabetes experts to establish        quality diabetes care is often called “evidence-based care”
                                                                                    but medications are often required.         standards of care for diabetes.                because it is consistent with treatment that research evidence
                                                                                    Type 1 must be treated with insulin.                                                       shows will produce the best health outcomes. Treatment
                                                                                    Controlling diabetes will prevent           In 2012 the American Diabetes Association      goals for type 2 diabetes include:
                                                                                    damage to other body systems,               partnered with the European Association
                                                                                                                                for the Study of Diabetes and issued new                 Hemoglobin A1c (HbA1c) control, with checks
                                                                                    including end stage kidney disease
                                                                                                                                recommendations on delivering treatments                 every three to six months
                                                                                    and blindness. Diabetes treatment also
                                                                                    focuses on controlling hypertension         that meet the needs of specific types of                 Blood pressure control at 130/80 mm/Hg or lower
                                                                                    and elevated cholesterol, which lowers      patients such as the elderly, chronically                Cholesterol and triglyceride levels management
                                                                                    the patient’s risk for cardiovascular       ill, and newly diagnosed. This is a change               with annual checks
                                                                                    disease linked to diabetes.                 from prior treatment guidelines that had                 (LDL cholesterol levels below 70-100 mg/dL)
                                                                                                                                a uniform HbA1c management goal for all                  Annual kidney function tests (microalbuminuria
                                                                                                                                patients.                                                and serum creatinine)
                                                                                                                                                                                         Annual eye exams to check for diabetic eye disease,
                                                                                    Why So Much Emphasis on                     Links to the 2012 standards, along with                  or more frequently as needed
                                                                                    Diabetes Care?                              a summary of changes and tools to                        Regular dental cleanings and exams
                                                                                                                                help physicians quickly identify care                    Smoking cessation treatment, if needed
                                                                                    Diabetes affects the health and             management goals, are identified in the                  Adoption of regular exercise program
                                                                                    productivity of the patients and families   Resources section of this Compendium.
                                                                                    who live with it. For most people, type                                                              Diabetes self-management education
                                                                                    2 diabetes is a progressive disease that
                                                                                    triggers a cascade of “co-morbidities”
                                                                                    or other health problems. Despite                                                          _________________________
                                                                                    knowledge of effective strategies to                                                       1 http://diabetes.niddk.nih.gov/dm/pubs/statistics/#pdc
                                                                                    manage diabetes, treatment adherence
10 |   Diabetes Care Best Practices Compendium                                                                                                                                                                             Narrative       | 11

                                                 Recommendations for treatments are reviewed and updated
                                                 each year by expert panels of the American Diabetes
                                                 Association. Medication treatments are intensified as                   Amerigroup Georgia AbsoluteCARE Quality Program
                                                 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                 The AbsoluteCARE Quality Program, an Avesis company,
                                                 such as high blood pressure or eye problems, additional                 offers a specialized patient-centered medical home for
                                                 treatments are needed to prevent worsening of the                       members with medical conditions such as diabetes and
                                                 conditions.                                                             hypertension who do not have a strong, established
                                                 Patients with type 2 diabetes are generally treated either              relationship with a primary care physician.
                                                 with “oral hypoglycemics” (pills to control blood sugar), or            The medical home, created for these members through this pilot program, represents a
                                                 injectable insulin, along with lifestyle changes such as better
                                                 nutrition, exercise, and weight control. If blood glucose is            comprehensive approach towards care that includes healthcare, wellness and prevention
   Coordinated Care in                           not adequately controlled, additional medications may need              services. This pilot program was developed as a solution to members who were in need
                                                 to be added over time. Patients may need insulin earlier if             of recurring healthcare services but were disconnected from a primary care provider. This
   Medical Homes May                             blood sugar cannot be controlled with lifestyle changes and             approach incorporates disease management services into a comprehensive, integrated
   Improve Diabetes Care                         medical therapy.                                                        patient centered medical home. The AbsoluteCARE Quality Program yielded extremely
                                                 For people who are severely overweight with a Body                      promising results. Average per member per month spending decreased by over 30%
   Best practice approaches to diabetes          Mass Index (BMI) of 35 or over and who also have poorly                 during the evaluation period. The most significant driver of savings was a decrease in
   care often involve a multidisciplinary        controlled diabetes, obesity surgery may also be part of the
   team. This enables providers to offer                                                                                 inpatient care though spending increased for primary care services and prescription drug
                                                 treatment plan. Bariatric surgery, as it is called, has been
   effective interventions across the            shown to reverse diabetes in up to 80% of patients. However,            spending. Emergency room visits decreased by over 45% among participants after the
   diverse elements of diabetes self-care.       bariatric surgery does have its own risks and complications.            referral to AbsoluteCARE was made and members opted into the program.
   Together these specialists cover:             These must be weighed against the risk of complications
                                                 that occur with type 2 diabetes.
           Nutrition and exercise
           Weight management
           Medication management                 Quality Gaps in Diabetes Care                                              Provider Factors: Diabetes care is complex and requires visits to several different types of providers.
           Prevention and smoking                                                                                           Physicians or other providers may not offer the proper treatments, tests and checks to manage
           cessation                             In spite of the research showing the health consequences of                diabetes, they may not intensify treatment when it is needed, or may not offer the right education that
           Other diabetes self-care              uncontrolled diabetes, patients very often do not get the best             patients need to “self-manage” their care.
           behaviors                             quality care. These gaps in care may be the results of any
                                                 combination of factors:                                                    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
   In recent years many provider practices               Health care system factors: The current health care                ready to make lifestyle changes such as healthier eating or exercising and/or patients may experience
   have adopted a model known as the                     system is not conducive to working through the                     health system/social barriers that affect adherence. All of these factors result in less than optimal “self-
   “patient centered medical home.”                      significant barriers experienced by patients with                  management,” e.g. the eating, exercising, and health management activities needed to successfully
   Medical homes are practices that have                 diabetes: visits are short, often acute illness prevents           manage diabetes.
   redesigned their office operations to                 attention to routine chronic health care needs, and
   be more accessible to patients and to                 the system may not be set up to deliver culturally                 Social Factors: Patients may not have insurance coverage for the health services, medications, family
   offer the full scope of multidisciplinary             appropriate care. Often, care is poorly coordinated                support or other support services they need to effectively manage diabetes. The Medicaid program
   care needed by patients with diabetes                 between the various physicians, hospitals, and other               makes important strides to ensuring health care access, but members may have disruptions in care
   and other chronic conditions. Medical                 providers treating the patient. There may also be                  when they lose eligibility for the program.
   homes also adopt more sophisticated                   missed opportunities to improve adherence with
                                                                                                                    The sections below illustrate how each of the key stakeholders – patients, physicians and other providers, and
   information systems to enable them                    visits and treatments and to deliver preventive
                                                                                                                    health plans – can influence better diabetes care.
   to more effectively track and meet                    treatments and counseling needed during visits.
   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.
12 |   Diabetes Care Best Practices Compendium                                                                                                                                                                                                    Narrative     | 13

  Chapter 2: Diabetes Prevention                                                                                                     While this compendium does not focus on diabetes prevention, a few of the health plan best practice examples in this
  Prevention related to diabetes takes place on two levels. First, “primary prevention,” — preventing diabetes entirely — is         publication describe plans’ community-based prevention strategies. In addition, the MHPA Center for Best Practices
  an important goal. Second, for people who already have diabetes, preventing worsening of the disease or progression to             Treatment Adherence Best Practice Compendium includes a number of outstanding examples of health plans’ community-
  heart and vascular complications is an important goal. “Secondary prevention,” as it is called, is achieved by implementing        based prevention initiatives. The compendium is available free from the CBP’s website, www.centerforbestpractices.org.
  appropriate screening guidelines to ensure early identification of people who have diabetes, and by providing evidence-based       Secondary Prevention: Prevention of complications of diabetes is the key objective in secondary prevention. Effective
  diabetes care, which includes careful attention to preventing complications.                                                       management of diabetes essentially is designed to prevent worsening and complications of disease. Diabetes treatment
  Primary Prevention: Type 2 diabetes is challenging to control yet largely preventable. Prevention of obesity is an important       goals include management of blood sugar and cardiovascular problems to prevent complications, and regular assessment for
  tactic for prevention of diabetes. Although individuals are accountable for maintaining a healthy weight, availability of          complications of diabetes.
  healthy food, places to exercise, and a culture that supports health have an enormous influence on individual choices. The         Early identification is a crucial element of diabetes treatment. Physicians evaluate risk of diabetes in the course of care and
  Institute of Medicine in a report, Accelerating Obesity Prevention, recently identified five strategies that prevent obesity and   deliver screening services. Health plans also have a role in identifying members who are high risk (through activities such as
  which they recommended be the core of community and national policy efforts. These are:                                            health risk assessments and health fairs) and connecting those members to physician care. High-quality diabetes care is one
           Integrate physical activity every day in every way                                                                        of the most effective strategies for preventing complications and co-morbidities. Most of the best practice examples in this
           Market what matters for a healthy life                                                                                    compendium describe health plan initiatives to identify members with diabetes, screen them for diabetes care quality gaps,
           Make healthy foods and beverages available everywhere                                                                     and help them to successfully manage their diabetes.
           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
                                                                                                                                     Chapter 3: Reducing Diabetes Racial and Ethnic Disparities
  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        Racial and ethnic minority groups often have a higher rate of chronic diseases including diabetes and also have more risk
  from prediabetes back to a normal risk level. The DPP offers many resources and recommendations to help individuals and            factors such as obesity, smoking, and lifestyles. According to the National Diabetes Education Program:
  communities take action to avoid diabetes.
                                                                                                                                             Non-Hispanic Whites: 15.7 million people, or 10.2 percent of all non-Hispanic whites aged 20 and older, have
  From a health plan perspective, diabetes prevention activities must target both individuals and communities. People at-risk                diagnosed and undiagnosed diabetes. 7.1 percent of all non-Hispanic whites aged 20 and older have diagnosed
  for diabetes can be identified early through “health risk assessments” that identify lifestyle factors and family heritage that            diabetes.
  may put people at higher risk for diabetes. Communities at-risk can be identified through demographic data. Working to                     African-Americans: 4.9 million people, or 18.7 percent of all non-Hispanic blacks aged 20 and older, have diagnosed
  care for high-risk individuals through care management, health promotion, and quality monitoring, health plans reduce risk                 and undiagnosed diabetes. 12.6 percent of all non-Hispanic blacks aged 20 and older have diagnosed diabetes.
  of diabetes for members. Community efforts focus on helping to develop exercise, nutrition awareness, and other lifestyle                  Hispanics/Latinos: 11.8 percent of Hispanics/Latinos ages 20 or older have diagnosed diabetes. Among Hispanics/
  improvement programs in the communities served by Medicaid health plans.                                                                   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
       Community-Based Prevention for Diabetes                                                                                               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.
       MHPA member organization UnitedHealthcare announced in October that                                                                   Asian-Americans: The rate of diagnosed diabetes in Asian Americans is 8.4 percent.
       it is bringing JOIN for ME , a proven community-based, childhood obesity

       lifestyle-intervention program, to Medicaid beneficiaries who live in the
       New Orleans area.                                                                                                             Quality Evaluation for Health
       JOIN for ME is a 12-month program that helps generally healthy children who are overweight or obese reach
                                                                                                                                     Medicaid health plans are taking action to reduce health care disparities. For example, many plans use community data to
       healthier weights and reduce the risk of many related health issues. This evidence-based program emphasizes                   identify communities with the highest risk factors relating to age, race, income, and health status. Health plans can develop
       whole-family lifestyle and behavior modification delivered in 16 weekly sessions, followed by monthly                         their own care management programs and partner with community organizations to develop culturally specific programs
       maintenance sessions for up to one year. JOIN for ME , which engages the entire family, has demonstrated
                                                                                                                                     and information on prevention and health education.
       promise to become a national model to meet the critical need for effective, accessible, and affordable treatment
                                                                                                                                     Health plans also routinely examine their own health care data to identify disparities and develop culturally appropriate
       for childhood obesity.                                                                                                        prevention and treatment approaches. Many plans are making strides in improving the quality of data to enable them to
       UnitedHealthcare and the Louisiana Alliance of Boys & Girls Clubs launched JOIN for ME at a Community
                                                                                                                                     evaluate quality by race and ethnicity. This will improve their ability to direct care to populations experiencing disparities in
       Forum that served as a call to action for the community to join forces to fight the childhood obesity epidemic                health outcomes.
       that is taking a devastating toll on families, communities, and the country. UnitedHealthcare Community Plan
       of Louisiana leaders noted that JOIN for ME 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_fights_
14 |   Diabetes Care Best Practices Compendium                                                                                                                                                                                    Narrative       | 15

       Important strategies to reduce disparities include:                                                                     Medicaid Health Plan Strategies to Measure and Reduce Disparities in Diabetes Care
               Ensuring that data have enough information on race, ethnicity, and other patient factors to help analyze for
               disparities                                                                                                     In October 2012, the Medicaid Health Plans of America (MHPA) Center for Best Practices hosted a workshop on
               Analyzing data to understand disparities                                                                        strategies to ensure quality care and reduce disparities in diabetes
               Developing culturally competent interventions                                                                   care and outcomes. The AmeriHealth Mercy Family of Companies
               Educating staff and providers on strategies for reducing disparities                                            (AMFC) outlined some of the data on disparities in the Medicaid
               Developing relationships with communities and individuals to build the trust needed for successful health       population of Philadelphia, and discussed its strategies to reduce
               partnerships, including use of peers and community health workers                                               disparities.
               Helping members to address their own priorities that may influence health, such as having adequate housing
               or access to food                                                                                               AMFC examined information on the Medicaid-covered population
               Seeking external guidance or standards to evaluate the organization’s cultural competency                       and identified 10 percent of adult members with diabetes. The
               Preventing the chronic health conditions that underlie disparities in disease prevalence and outcomes.          majority of members with diabetes are African-American and non-
                                                                                                                               Hispanic whites. Adult African-American members with diabetes
       Disparities in care and outcomes occur in racial and ethnic minorities, and also in some high-risk populations          were identified as more likely to have care gaps than other members. In addition, data showed high use of
       such as the homeless, people with mental illness, or people in underserved communities. Many of the best                emergency and hospital services. Of the adult African-American members with diabetes, 25.8 percent had at
       practice examples in this publication describe health plan initiatives to meet the needs of specific populations with   least one emergency room visit and 7.5 percent had at least one inpatient admission. This information shows
       community-based services, peers, and culturally competent services.                                                     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
          Reducing Diabetes Disparities in People with Serious Mental Illness                                                          evaluation strategies, to improve ability to analyze and meet member needs.
                                                                                                                                       Providing cultural competency training to staff.
          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                    As a result of adopting these strategies, AMFC’s health plans achieved the National Committee for Quality
          syndrome, a precursor of diabetes. The initiative targets psychiatrists prescribing Second                           Assurance’s Multicultural Health Care Distinction.
          Generation Atypical Antipsychotic Medications (SGAs). The goal is to increase screening for risk                     At the clinical level, AMFC interventions to reduce disparities include:
          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                                Intensified approach to members with diabetes with the highest number of emergency room and
          primary care for their members with diabetes risk factors. Diabetes monitoring scores were 82                                inpatient events, and on multiple medications.
          percent in 2012, a dramatic increase from the 11% monitoring rate when the program began in                                  Implementing home-based health care services and individualized member treatment plans to build
          2006. VBH-PA providers are also improving in referring at risk members to primary care.                                      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.
16 |   Diabetes Care Best Practices Compendium                                                                                                                                                                         Narrative        | 17

       Chapter 4: Medicaid Health                                                                                             Using care management programs to educate and support patients in making lifestyle choices that
                                                                         Midwest Health Plan                                  prevent and manage diabetes. Amerigroup’s AbsoluteCARE medical home initiative and the Select
       Plan Innovations in Improving                                     Diabetes Control Network:                            Health In Control program are examples of innovative care management programs.

       Diabetes Care                                                     Midwest Health Plan created the
                                                                                                                              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
                                                                         Diabetes Control Network to identify                 It Matters program uses innovative visual aids to show members a “Healthy Plate” and to help them
       Diabetes affects both physical health and quality of life of      members with diabetes and help                       understand healthy eating for diabetes prevention and control.
       patients. States’ Medicaid costs for diabetes are high, and the   improve care. The Diabetes Control
       condition is challenging for physicians and other providers to                                                         Connecting with members on health education through interactive websites that offer health
                                                                         Network identifies members with                      information, health risk assessments, and games. The Buckeye Community Plan’s collaboration with
       identify and manage. Medicaid health plans are positioned         diabetes through a comprehensive
       to leverage their influence with a variety of stakeholders to                                                          AT&T on cell phone-based diabetes education shows how health plans are testing and trying out new
                                                                         software system that supports                        technologies to improve health.
       improve diabetes care.
                                                                         Midwest Health Plan’s (MHP) disease
       Health plans have an important role in using information,         management, case management, and                     Offering diabetes disease management directly to patients in need of additional support and education.
       patient and provider contacts, and payment incentives to          utilization management functions.                    WellCare Health Plans, Inc. is implementing the HealthConnections: Community-Based Disease
       improve diabetes care. Many health plans have developed care      This system provides for an integrated               Management Pilot in partnership with a Texas-based academic institution, with the goal of increasing
       coordination programs to help members navigate their health       and efficient way to identify members                availability of trained practitioners to improve diabetes care.
       care needs. Health plans also deliver “disease management”        eligible for the program, stratify based             Contracting with high-quality physicians and increasing patient awareness of high-quality diabetes
       services that offer education, counseling, and information on     on severity of disease, and track                    providers such as those recognized in diabetes care by NCQA.
       treatment to members identified as having diabetes.               member interventions. Members
                                                                         enrolled in the Diabetes Control                     Partnering with physicians and other practitioners to help them understand opportunities to improve
       Using data and information effectively is an important element                                                         diabetes care. Volunteer State Health Plan’s program to educate physicians on comprehensive diabetes
       of finding which patients have or are at risk for diabetes, and   Network receive information and other
                                                                                                                              care is an example of this approach.
       helping to close gaps in quality for these groups. Health         materials focusing on the disease
       plans use their claims (provider bills) and enrollment data       process and complications, medication                Using incentives to encourage members to use high-quality providers and to participate in diabetes
       systems to identify patients with diabetes and understand         use and adherence, nutrition, caregiver              management programs. The MDwise program and the Health Partners’ You Count program both
       which services they are receiving. Health plans may also offer    resources, self-management skills,                   include incentives for members to engage in prevention and health improvement behaviors.
       “risk assessment” surveys online or in person to help patients    treatment plan, lifestyle issues affecting
                                                                                                                              Collaborating with communities and community organizations such as schools, health departments
       understand familial and behavioral factors that might put         the disease state, depression, and
                                                                                                                              and fitness organizations to develop prevention and wellness programs. UPMC for You’s Community
       them at risk of diabetes. Plans use this information to develop   the importance of follow up with                     Health Worker Program hires members of the community to build trust and carry out a neighborhood-
       patient and provider education and care management services       physicians. Members also receive                     based health and wellness initiative.
       that support the patients and improve care.                       reminders and incentives to complete
                                                                         recommended diabetes visits and                      Partnering with states to carry out payment incentive demonstration programs to reward providers
       Through use of data, health plans can also see whether                                                                 for better quality care.
                                                                         testing. Primary care providers receive
       patients are going to their doctor for diabetic screening tests
       and can alert providers and patients of needed care. For          education and information to improve         Medicaid health plans are accountable for their diabetes care results and report HEDIS measures to show
       example, pharmacy claims serve as a source of information         the diabetes services they provide           their performance. Many state Medicaid programs use health plans’ HEDIS reports to produce health plan
       on how frequently patients are refilling medications and          to members. Midwest Health Plan              performance report cards or other information for patients. The National Committee for Quality Assurance
       whether they are getting essential medications. Plans use this    has seen improvements in all HEDIS®          also reports data on diabetes care quality. The following tables show health plan performance on multiple
       information to address adherence to medications, either by        measures for comprehensive diabetes          diabetes indicators. The lower performance of Medicaid plans shows the challenges of working with a low-
       alerting the doctor or contacting the member directly. They       care during the past three years.            income, high-disparities population. But, the steadily improving performance illustrates that plans’ strategies
       may also identify safety concerns if there are duplicates or      HbA1c testing increased from 82% to          are evolving to effectively serve the Medicaid population.
       drug interactions. The best practice example from PerformRx       93%; Eye exams increased from 60%
       in this publication shows how one plan uses pharmacy data         to 62%; LDL screening from 79% to
       to identify members who have 15 or more prescriptions and         80%, and monitoring for nephropathy
       helps those members get on the right medications.                 increased from 87% to 98%.
       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.
18 |   Diabetes Care Best Practices Compendium                                                                                                                                                                         60   N A T I O N A L C O M M I T T E E F O R Q U A L I T Y A S S U R A N C E • E A R L Y E D I T I O N , O C T O B E R Narrative
                                                                                                                                                                                                                                                                                                                                              2012        | 19

                                T H E S TAT E O F H E A L T H C A R E Q U A L I T Y 2 0 1 2 • H E D I S M E A S U R E S O F C A R E   59

       The following charts were reprinted from the National Committee for Quality Assurance (NCQA)
       from the “Focus on Obesity and on Medicare Plan Improvement” report.
       The entire State of Health Care Quality, 2012 report can be accessed at:

                                                                                                                                                                                 CHRONIC CONDITION MANAGEMENT
                                                                                                                                                                                                                       LDL CHOLESTEROL SCREENING                                              LDL CHOLESTEROL CONTROL
20 |   Diabetes Care Best Practices Compendium                                                                                                 Best Practices     | 21

                                                 Chapter 5: Diabetes Care Best Practices Submissions
                                                 Buckeye Community Health Plan (Centene® Corporation) and
                                                 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.

          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
             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.
                                                                                                                                    geographic location: Buckeye Community Health Members in the Southwest, Northwest, Northeast and East
           B. Comparisons were made between the program participants and a similar population (high-risk, type II                   Central areas of Ohio (see service map below):
              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

                            Program        Member   Pre 90 Post 90                                              Hospital
                                                                                 Participation ER Visits
                      Participation Status Count     MM     MM                                                   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.
                                            Pre 90 Post 90
                            Program                            %     Pre 90 Post 90 Per
                                           Hospital Hospital
                      Participation Status                   Change Per 1,000 1,000
                                            Visits   Visits
                               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       Pre 90 ER Post 90   %     Pre 90 Post 90 Per
                      Participation Status Visits ER Visits Change Per 1,000 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

           C. We also measured member engagement and utilization throughout the initiative as number of blood                       contact:      Artie Paniagua MBA, BSN, RN
              sugar entries through the mobile application. Prior to implementation, the decision was made to require               		            Director Clinical Policy and Support, Centene Corporation
              participants to record a minimum of seven entries per week (one entry per day average). As shown below,               		            (314) 725-4706 ext. 25038; apaniagua@centene.com
              members maintained an average level of five to six entries per week throughout the initiative.
24 |   Diabetes Care Best Practices Compendium                                                                                                                                                                            Best Practices     | 25

       UPMC for You                                                                                                        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
       Community Health Worker Program                                                                                     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
       description: The Community Health Worker Program is a collaborative effort between UPMC for You and                 classes offered at the community centers, such as exercise. We are currently in the process of working on scheduling
       various community centers located in areas with a high concentration of African Americans. These communities        the Stanford chronic education classes in each of the four community centers. They CHWs will help to organize
       have health care disparities. The program is a neighborhood-based health and wellness initiative. The objectives    and promote the event. Those with diabetes will be invited to attend these classes.
       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        outcomes: The evaluation for this program is not set until 2013.
       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              geographic location: The program has been implemented in Pittsburgh, Pennsylvania in four communities
       hovers around 35 to 40%. Poor addresses and phone numbers, and lack of relationships with the health care           through the Hosanna House, Inc., Bidwell Presbyterian Church and Manchester Youth Development Center, Hill
       community make it difficult to reach a large portion of our members. Community-based programs, placed in            House, Association and the Kingsley Association.
       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          contact:        Debra Smyers
       services, and satisfaction with the experience of care.                                                             		              Senior Director Program Development, UPMC for You
                                                                                                                           		              (412) 454-7755; smyersd@upmc.edu
       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         Midwest Health Plan
       chronic conditions, in addition to providing support to non-UPMC for You community residents.                       Diabetes Control Network
       key objectives:                                                                                                     description: Midwest Health Plan created the Diabetes Control Network to identify members with diabetes
             Improve the health of the population                                                                          and help improve care. The Diabetes Control Network identifies members with diabetes through a comprehensive
             Enhance the patient experience of care (including quality, access and reliability)                            software system that supports Midwest Health Plan’s (MHP) disease management, case management, and utilization
             Control or reduce the per capita cost of care or increase efficiency                                          management functions. This system provides for an integrated and efficient way to identify members eligible for the
             Reduce disparities in care of racial and ethnic minorities                                                    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,
       actions taken: UPMC for You has provided the funding to hire four Community Health Workers in May 2012.             medication use & adherence, nutrition, caregiver resources, self-management skills, treatment plan, lifestyle issues
       These individuals were hired in conjunction with the community centers and are residents of the community.          affecting the disease state, depression, and the importance of follow up with physicians. Members also receive
       They have begun to talk with community stakeholders, identified the health care and other social support services   reminders and incentives to complete recommended diabetes visits and testing. Primary care providers receive
       available, and are gathering information on the unique needs of those communities. UPMC for You partnered           education and information to improve the diabetes services they provide to members. Midwest Health Plan has
       with UPMC Family Medicine to develop a training program for the Community Health Workers. A UPMC                    seen improvements in all HEDIS® measures for comprehensive diabetes care during the past three years. HbA1c
       physician provided key elements of that training. The Community Health Workers devote 40% of their time to          testing increased from 82% to 93%; Eye exams increased from 60% to 62%; LDL screening from 79% to 80%, and
       activities directed by the centers and 60% on health plan directed activities. The Community Health Workers are     monitoring for nephropathy increased from 87% to 98%.
       meeting with individuals in the communities with the goals to:                                                      Midwest Health Plan continues to implement the Diabetes Control Network program to address the following
               Identify needed health care or social services and assist residents in accessing those services             issues:
               Provide culturally appropriate health care related information                                                       According to the 2011 Michigan Diabetes Burden Report, Diabetes affects 25.8 million Americans (8.3%
               Give informal counseling and guidance on heath behaviors and self-management of chronic conditions                   of the population) and an estimated 1.65 million Michigan citizens. Diabetes costs the United States
               Identify health and wellness programs that can benefit the resident                                                  $174 billion annually and over $9 billion per year in Michigan. Total medical costs for Midwest Health
               Advocate for the individual                                                                                          Plan’s members with diabetes were $14,492,819 and prescription costs were $6,773,941 for a total cost of
               Coordinate the promotion of health and wellness programs                                                             $21,266,760.
               For UPMC for You members, provide referrals to health plan care management programs and coordinate                   Michigan’s 2011 Behavioral Risk Factor Survey reports that diabetes was the seventh leading cause of
               accessing services for those members                                                                                 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.
Briefly identify specific outcomes / data related to the initiative identified in question 3. Use speci
                                                                                                                                  where possible. (Limit to one to two paragraphs)
26 |   Diabetes Care Best Practices Compendium                                                                                                                                                                            Best Practices      | 27

                                                                                                                                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
       key objectives:                                                                                                      outcomes  : MHP measures
                                                                                                                                (nephropathy)   monitored.
                                                                                                                                                      the effectiveness and outcomes of our programs through annual HEDIS®
             Improve the health of the diabetic population                                                                  indicators and results. Processes are then refined based on these outcomes. Annually, MHP performs
             Enhance the patient experience of care (including quality, access and reliability)                             program-specific chart audits to ascertain the effectiveness     of the interventions using HEDIS® indicators.® The
                                                                                                                                   MHP     provides
                                                                                                                                                  used provider-specific      HEDIS performance            feedback    annually.    HEDIS
                                                                                                                                                                                                                                        diseasemeasures are

             Improve quality of care in a specific clinical area (medication adherence, patient education, lifestyle        HEDIS®   indicators        are: HbA1c testing; LDL-screening;      eye exam (retinal)   performed;  kidney
             changes, specialty care, etc)
                                                                                                                                   assess the
                                                                                                                            (nephropathy)        effectiveness of health management programs, so this intervention provides information
                                                                                                                                   PCP’s    on  the  extent to HEDIS®
                                                                                                                            MHP provides provider-specific       which members
                                                                                                                                                                          performance arefeedback
                                                                                                                                                                                           receiving    care in
                                                                                                                                                                                                   annually.     compliance
                                                                                                                                                                                                              HEDIS®    measureswith   the to
                                                                                                                                                                                                                                  are used clinical guidelin
                                                                                                                            assess senior   memberofofhealth
                                                                                                                                   the effectiveness      the Quality
                                                                                                                                                                               programs, so Department      confers
                                                                                                                                                                                              this intervention        withinformation
                                                                                                                                                                                                                 provides    physicianstoregarding
                                                                                                                                                                                                                                           PCP’s      their ou
       actions taken: The initiatives of the Diabetes Control Network include:                                              on thecompliance
                                                                                                                                    extent to which   members   are  receiving care in compliance    with the clinical guidelines.  A senior
                                                                                                                                                   members, engages in instructional dialogue, and provides patient-specific compliance
             Members enrolled in the Diabetes Control Network receive information and other materials quarterly             member    of the Quality
                                                                                                                                   for follow up and  Management      Department confers with physicians regarding their out of compliance
             which focus on disease process and complications, medication use & adherence, nutrition, caregiver             members, engages in instructional dialogue, and provides patient-specific compliance tools for follow up and
             resources, self-management skills, treatment plan, lifestyle issues affecting the disease state, depression,   documentation.
             and the importance of follow up with physicians.
                                                                                                                                   The ongoing
                                                                                                                            The ongoing             interventions
                                                                                                                                           interventions              of the
                                                                                                                                                          of the diabetes     diabetes
                                                                                                                                                                           disease        diseaseprogram
                                                                                                                                                                                   management       management       program have
                                                                                                                                                                                                            have demonstrated          demonstrated an
                                                                                                                                                                                                                                 an improvement
             Community health fairs are held where diabetes services are performed such as dilated eye exams, blood         in the improvement       in the
                                                                                                                                   delivery of services  and delivery    of services
                                                                                                                                                              better patient           andawareness.
                                                                                                                                                                             & physician     better patient
                                                                                                                                                                                                        This is&  physician
                                                                                                                                                                                                               evidenced       awareness.
                                                                                                                                                                                                                           by the             This is evidenc
                                                                                                                                                                                                                                   HEDIS® results
             pressures, and podiatrist foot exams.                                                                          below:the HEDIS® results below:
             Educational materials and preventive health guidelines are distributed to members to assist in self-                         ®
             management.                                                                                                           HEDIS Measure
             A Health Risk Assessment (HRA) is sent to all new health plan members upon enrollment. Members are                    Comprehensive Diabetes Care (CDC)                                       2010     2011        2012
             eligible for a $5 gift card incentive for the return of an HRA. Basic educational material is sent when the           *HbA1c testing                                                         82.1%     88.5%       92.7%
             form is returned with a positive response on the diabetes question and members are also enrolled in the                *Eye Exam                                                             59.7%     61.3%       61.5%
             disease management program.
                                                                                                                                    *LDL‐C Screening                                                      79.2%     83.4%       84.7%
             Incentive reminder letters are sent to members who are due for the following annual diabetes screening                 *Monitoring for Nephropathy                                           86.5%     92.3%       97.8%
                  Lipid screening
                  Microalbuminuria                                                                                                 8. location
                                                                                                                            geographic Geographic  Location
                                                                                                                                              : Southeast Michigan
                  Dilated eye exam                                                                                                Southeast Michigan
                  Hemoglobin A1C                                                                                            contact:          Andrea Fogarty
                                                                                                                            		 9.             Director,
                                                                                                                                              ContactHealth   Management,
                                                                                                                                                        Information        Midwest
                                                                                                                                                                       (to be listedHealth
                                                                                                                                                                                     in thePlan
       Members can receive a $10 gift card per completed test. Members must return the form via fax/mail with their         		                (313) 586-6071; afogarty@midwesthealthplan.com
       Primary Care Physician’s (PCP) signature to receive the gift card.
                                                                                                                                  Contact Name: Andrea Fogarty
              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
              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.
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