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Population Health

Closing the Gaps in Diabetes Care

Closing the gaps in diabetes care by focusing on critical performance metrics is essential. For patients with diabetes, these critical metrics include hemoglobin A1c (Hb A1c) levels, dilated retinal eye exams, and kidney function screening.

HEDIS Criteria

HEDIS criteria stipulate these indicators must be addressed during the measurement year, and documentation must include:

  • The date of the blood draw, test performed, and result. If multiple tests were completed, the most recent test date and result are used. The goal for performance compliance is an Hb A1c level less than 8%.
  • The date, test (dilated or retinal exam), eye care professional’s name and credentials (optometrist or ophthalmologist), and results.
    • If the eye exam is negative for retinopathy, then follow up every two years is recommended.
    • If retinopathy is present, yearly follow up is required.
  • The date of the urine test for albumin or protein, or evidence of a visit to a nephrologist, renal transplant, medical evaluation for renal or kidney problems, or use of ACE inhibitor or ARB therapy.

Compliance with these criteria in the limited time allotted for a patient encounter can be challenging. Adequate preparation and being proactive in conjunction with consistent follow-up are essential to maximize each encounter. Creating a system and enlisting the aid of practice team members can optimize each visit.

After the visit, consistent follow-up is essential to ensure adherence to the prescribed plan. A communication system is necessary to evaluate the patient’s status, adjust the patient’s plan of care, and assess self-management. Tools such as automated notification systems, patient portals, and care coordinators can be effective means for follow-up.

Ultimately, strategies focusing on key performance metrics incentivize all involved, closing the gaps in diabetes care to deliver quality care that benefits everyone.

Diabetes Education Is Key

For many patients, diabetes is a challenging disease to manage. These patients may benefit from targeted education to support them in self-monitoring, medication adherence, and lifestyle behaviors such as healthy eating.

Diabetes self-management education helps patients acquire the knowledge and skills necessary for diabetes self-care. Studies show that people who receive diabetes education are more likely to use primary care services; take medications as prescribed; and control glucose, blood pressure, and cholesterol.

Help Your Patients Take Control of Their Diabetes

It’s important to talk with your patients about the role of self-management in achieving treatment and quality-of-life goals. Temple’s Real World Diabetes Program offers classes to inspire patients to make healthy lifestyle choices and gain control of their diabetes. The program is offered at multiple locations, including the TUH-Northeastern Campus. Patients can also see a Temple endocrinologist to help manage medications and reduce the risk of comorbidities.

To schedule an appointment with a Temple endocrinologist, call 800-TEMPLE-MED.

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