C. Process of Care Changes
F The endocrinologist provided education on
diabetes management to PCPs via lectures,
printed handbooks, and best-practice Internet
links and conducted educational programs
across the entire system. A pocket booklet
was designed and distributed to all providers.
The booklet contained ADA guidelines for
blood glucose control, including timelines for
intensification of treatment. Guidelines were
developed and made available in every patient
chart via the EHR.
F MAs provided initial diabetes education and
helped with downloading patients’ glucose
meter readings at PCPs’ offices.
F Diabetes education referral processes were
clearly delineated in the EHR, with specific
details of the type of educational interventions available.
F Endocrinologist-led case discussions were
held every two to three months at each site.
One to two weeks prior to these discussions,
office managers used the diabetes registry
to create a list of patients with an A1C >9%.
This list was available to all providers, and
selected cases from the list were discussed
with the endocrinologist. Providers were
encouraged to discuss cases via web links,
email messages, and messages in the EHR.
The administration compensated the single
endocrinologist for 20%–25% of her time for
F Regular team member meetings were initiated
to discuss feedback from providers.
The goal was to reduce the total number of
patients with diabetes with an elevated HbA1C
greater than 9% from 25% to 20% at the end of
The program was developed and implemented
in 2015 at 22 primary sites. Within the relatively
short timeframe of 18 months (2015–2017),
highly encouraging results were seen, including:
F Number of patients identified as having an
A1C >9% decreased from 2,500 patients at the
baseline to 1,460 patients after 18 months.
Across all sites, the overall A1C >9% rate
dropped from 25% to 20.9% among patients
with diabetes. For non-Medicaid patients,
there was an accelerated decrease, from 25%
to 12.62% (see Figure 1). Improvements were
identified at all sites. Improvement was also
found in the Medicaid population, although
not to the same extent as with non-Medicaid
patients (35% to 21.8%).
F This same improvement has been maintained
at all “primary” sites to date (see Figure 1).
F Diabetes education referrals increased by
more than 100 patients in one year. These
cASE STUDY Figure 3
A1C: Secondary Region 2–Non Medicaid, June 2018–
Nov- 18 Feb- 19 Aug- 18 Dec- 18 Jun- 18 Mar- 19 Sep- 18 Jan- 19 Jul- 18 Oct- 18