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Managing Our Diabetic Panel – Adirondack Medical Practice

Our practice identified while evaluating our Diabetic panel reports, many patients had not completed having their labs or diabetic eye exam completed.  The creation of a team based approach to managing our diabetic population was created.

The diabetic panel reports are pulled monthly, to ensure that the diabetic patients are seen at least every 3 to 6 months.   Internal review of the reports identified that many of the labs were not being done once the patient left the practice.  The providers created a set of standing orders that the LPN can create the orders for a hemoglobin A1c, urine micro albumin and an eye exam referral when it would be due.   The practice purchased a CLIA waived in house testing kit to perform A1c’s at the point of care, as well as a CLIA waived in house urine micro albumin/creatinine analyzer for the office.  Patients identifying as having barriers to complete these test, now have the convenience of completing at their appointment.  The practice created a specific appointment type for the diabetic patients to help the clinical staff identify the needs of the diabetic patient and perform the specific procedures during these visits.

Before the DM visit, the nurse reviews with the patient:

• Review the diabetic measures that need to be completed
• Print out the patients’ specific diabetes assessment form
• Have the patient remove their shoes and socks for their foot exam
• Review any overdue measures
• Perform any labs as needed
• Leave the assessment form in the room for the provider to discuss with the patient.
• Provider gives the form to the patient to take home as a reminder of what measure(s) they need to get completed.

The practice created a Diabetic Nurse Visit training program and purchased the tools they need to provide the education the providers would like the patient to receive.  If the provider identifies the patient needs further education the nurse can provide any of the following: diet/nutrition, medication management, or proper technic on how to keep track of sugars and insulin use for example.

The front staff is trained to look at the patient’s history when they call for refills and make sure the patient has been seen at least every six months.  Providers are not allowed to give more than a 90 day supply of a patient’s chronic illness medication, to ensure that patients with chronic illnesses are being seen appropriately.The practice runs a report every 3 months specifically for diabetic patient with a current A1C > 9.  The LPN’s call each patient and ask them how they are doing with their medication, diet and if they have any questions. They offer to set them up with a nurse visit to educate on a simple diet plan for diabetes, review all of the patients medications and how to properly take them, hand out BS logs, and a diet plan guide brochure, they also set up the patient for a referral to a DME or nutritionist if they feel the patient needs further diet education.

The process has been successful in creating a team approach to managing our diabetic panel, thus creating better outcomes for our patients and overall quality program.

Coalition Takes Aim At Diabetes, Chronic Disease Prevention

A new network of health care providers, public health agencies, and nonprofits are working to reduce the prevalence of diabetes and other chronic diseases across the region.

The North Country Chronic Disease Prevention Coalition aims to build a region-wide system that will ultimately have the capacity to provide evidence-based prevention and self-management education to at least 2 percent of the estimated eligible patient population in any given year.

The Heart Network convened the Coalition in order to build on the success of a health systems program that increased identification and treatment of prediabetes in Adirondack Health’s primary care clinics. This program — Moving Forward Together to Prevent diabetes — was funded with a three-year grant from Excellus Blue Cross Blue Shield and included the addition of health coaches to primary care teams as well as the implementation of multiple standing orders and the establishment of a Centers for Disease Control (CDC) recognized diabetes prevention program. Outcomes were so favorable that the Heart Network was able to pursue and secure funding to support the replication and expansion of the program across the North Country.

Using the four domains of the CDC’s chronic disease prevention system as a framework — epidemiology and surveillance, environmental interventions, health system interventions, and clinic-community interventions — the Coalition has been busy in 2021. Focuses this year include:

• Developing a plan for data collection and analysis needs.
• Participating with local projects that aim to increase access to healthy foods and opportunities for physical activity.
• Promoting the adoption of policies and/or practices that increase identification and referral to evidence-based programs (EBPs).
• Ensuring availability of EBPs.
• Developing a system to support the referral & enrollment process.

In particular, health care providers play a critical role in treating patients with prediabetes and diabetes and helping them find community-based services to assist them in adopting daily routines and practices to get and stay healthy. To this end, the Coalition launched a referral system to link prediabetic and diabetic patients with local, evidence-based programs that can help them prevent or better manage their condition. NY Connects — a statewide directory of health, home care, transportation, and other resources — provides follow-ups to patients referred to help them understand community-based program options and get them enrolled.

The North Country Chronic Disease Prevention Coalition understands that people in isolated, rural communities like many of those in our region struggle to control their condition. As a collective, the Coalition believes that steps like the referral system will empower individuals to take control of their own health.

As communities across the country recognize National Diabetes Month and raise awareness about this condition, the Coalition urges people with prediabetes and diabetes to talk to their primary care providers to learn about local, community-based services that can help — and in turn, we hope providers will continue to refer patients to evidence-based programs.

Ann Morgan is executive director of the Heart Network. To learn more about the North County Chronic Disease Prevention Coalition, email amorgan@heartnetwork.org.

Quality & Performance Update

Quality Gap Closure with Supplemental Data

We are nearing the end of the year, which means our gap reports for 2021 are coming to a close.  Supplemental data is important in the overall quality score of the ACO and can be the difference in shared savings.

To decrease the burden of supplemental data submission, it is important to look at the workflows in the practice.  Is your practice utilizing pre-visit planning to look at the preventive gaps that are identified? Are CPT – 2 codes and/or Z codes being used to close gaps in care at the time of a well visit?   Utilizing the codes will decrease the burden of providing supplemental data, by closing the gaps when a claim is submitted.  Here are several examples:

• If a patient has had a total hysterectomy utilize the code Z90.710 – acquired absence of both cervix and uterus, to remove from future gap lists.Documentation in the patient history of a hysterectomy will not close a gap in care – documentation must state “Total” or “Complete” to close a gap in care if utilizing a visit note and/or past medical history, which must include a date.
• If you provide point of care A1c testing the following CPT 2 codes will not only close a gap, but allow you to monitor the control of your diabetic panel and there may be an incentive available through the different payer incentive programs:
  • 3044F:HbA1c < 7
  • 3051F:HbA1c greater than or equal to 7.0 and < 8.0
  • 3052F:HbA1c greater than or equal to 8.0 and less than or equal to 9.0
• CPT 2 codes which can be used to close Controlling High Blood Pressure gaps:
  • 3074F:Most recent systolic blood pressure <130mmHg
  • 3075F:Most recent systolic blood pressure 130-139 mmHg
  • 3078F:Most recent diastolic blood pressure < 80 mmHg
  • 3079F:Most recent diastolic blood pressure 80-89 mmHg

These are just few examples of the efficiencies that can be built into your processes that will decrease the burden to you and your staff, which will capture the quality metrics, without having to supply duplicative documentation to close gaps.

ADK ACO and Highmark BS Collaboration Webinar: HEDIS 2022 Updates

Date: November 17, 2021
Time: 12:15 P.M. – 1:00 P.M
For more information contact Brenda Stiles

ACO Spotlight

New report on smoking prevalence reveals encouraging signs

SARANAC LAKE — A new report from the New York State Department of Health’s Bureau of Tobacco Control reveals significant decreases in the prevalence of smoking in adults across the North Country.

The report analyzes smoking prevalence data over a four-year timespan from 2014 to 2018. Clinton and Franklin counties each saw distinct decreases between 2016 and 2018: 24.7 to 19.9 percent in Clinton County and 28.8 to 20.6 percent in Franklin County. In Essex County, the rate dropped from 16.8 to 16.4 percent.

“We find the latest data from the state Bureau of Tobacco Control encouraging,” said Joey Boswell, who coordinates the Heart Network’s Health Systems for a Tobacco Free North Country program, which provides resources and consultation to health care providers to help increase the delivery of comprehensive, evidence-based treatment for nicotine addiction.

“It’s difficult to make a direct correlation between the work of our partners and the latest data, but we believe it’s fair to say their work played a role,” Boswell said. “While we’re encouraged by these positive strides, we can’t let up — other counties in the North Country saw smoking prevalence rates trend upwards, so there’s still work to do.”

The report, which compiles data from the 2016 and 2018 New York State Behavioral Risk Factor Surveillance System surveys, reveals that statewide smoking prevalence among adults was 12.8 percent in 2018. These surveys help health care providers, tobacco cessation specialists and community health organizations identify geographical disparities, track progress of cessation programs and evaluate the effectiveness of policies. County-level data can also help develop and enhance intervention programs.

“Tobacco use remains the number one cause of preventable death and disease in our country,” Boswell said. “Our Health Systems program can link providers with resources to help patients quit, but we also urge those physicians and primary care specialists to simply start conversations with those individuals. In any given year, seventy percent of tobacco users will visit a health care provider. Clinicians have an opportunity to treat tobacco use and dependency as they would any other chronic disease, with behavioral counseling and pharmacotherapy.”

“Nationwide research shows that just three to five minutes of brief counseling can double a patient’s chance of quitting, and long-term quit rates increase twenty percent with consistent follow-up counseling and up thirty percent when counseling is combined with pharmacotherapy,” Boswell noted.

The report on smoking prevalence in adults comes on the heels of another promising report on youth tobacco use in New York. The state Department of Health’s 2020 Youth Tobacco Survey found that less than 3 percent of high school students smoke, down 27.1 percent from 2000.

“These reports are proof that evidence-based treatment and sound public policy can improve health outcomes for all,” said Ann Morgan, executive director of the Heart Network. “We send our gratitude to the healthcare providers and public health agencies who are committed to helping people get and stay healthy.”

To learn more about the Heart Network’s Health Systems for a Tobacco Free North Country program, contact Joey Boswell at jboswell@heartnetwork.org. For resources to help you quit, check out New York State Smokers’ Quitline at nysmokefree.com or call 1-866-NY-QUITS.

The Heart Network also administers the Creating Health Schools & Communities program in Franklin County, which works to increase access to healthy foods and opportunities for physical activity in schools, communities and early childcare settings, as well as the North Country Chronic Disease Prevention Coalition, a network of healthcare providers, community-based organizations, and other regional stakeholders working to replicate and expand evidence-based diabetes prevention programs across the North Country.

To learn more, contact Ann Morgan at amorgan@heartnetwork.org or (518) 891-5855. To learn more about the Heart Network, visit heartnetwork.org.