State Approaches to Diabetes Care Quality Improvement

The following sections summarize various kinds of State diabetes quality improvement approaches relating to partnership/planning activities, program development, and dissemination. A few States are highlighted under each type of approach to illustrate examples of best practices.

States have undertaken a variety of diabetes initiatives over the years, most of which have been spearheaded by State DPCPs. Although the mandate of State DPCPs covers many aspects of diabetes prevention and control, States DPCPs have included quality improvement as a part of their diabetes work. States have used CDC funding to establish creative programs to address diabetes quality improvement, ranging from using the Chronic Care Model in collaboratives to developing diabetes guidelines.

There are also stand-alone State initiatives that are not directly connected to CDC and State DPCP efforts. States have established diabetes disease management programs in Medicaid and have partnered with the private sector on quality improvement related to diabetes. Many States have also tried to integrate CDC-funded efforts with private-sector and Medicaid efforts.

Types of Approaches to Organizing Diabetes Programs States structure their public health programs differently. Listed below are samples of different ways that States have approached diabetes quality improvement programs. Regional structures Georgia provides diabetes services through its seven existing public health districts. Pilot projects Massachusetts worked in three pilot communities to enhance diabetes care by integrating the health system with community diabetes development. Community-based grant support New Hampshire and South Carolina conduct many diabetes activities through grants to community health centers or community organizations throughout the State.

The range of State activities makes it difficult to present all of the possibilities. Instead, various activities and programs States have used to address diabetes care quality are listed below. Except where other citations are provided, the information provided below was derived from a review of State health department Web sites, CDC resources, Internet research, and in-person interviews with State agency officials. A focus group of State officials and diabetes experts also assisted with formulating the categories for State diabetes quality improvement approaches. State examples were selected in order to provide a sampling of State efforts that reflects regional, size and funding differences between States. Also, the uniqueness of the State efforts in relation to similar programs was taken into consideration. Although not an exhaustive list, it demonstrates a range of efforts States have undertaken related to diabetes quality improvement. These efforts may be cataloged as follows:

Partnership/Planning Activities

• Coalitions.
• Advisory bodies and councils.
• Working across State agency lines.

Program Development

• Developing and complying with diabetes guidelines.
• Data measurement and reporting.
• Use of technology.
• Self-management/patient education.
• Collaboratives.
• Provider training.
• State disease management programs.

Dissemination

• Raising awareness through public relations.
• Minority and rural outreach.

Partnership/Planning Activities

Coalitions

Creating networks of support has been critical for States that have established far reaching programs addressing diabetes quality improvement. Coalitions bring together a broad variety of stakeholders in a State to work together to identify areas of strength, common objectives, and gaps in service. They also develop plans to assure that the essential treatment and educational services for managing diabetes are in place in a community. Coalitions also include community representatives and nontraditional partners such as the corner grocery store owner, faith communities, health organizations, social service agencies, and more. Coalitions can develop strategic nontraditional plans and establish measures and processes for determining community success.

"Partnerships are key to everything we do — they are key to public health. The strength and commitment of our partners underlies our success." — Wisconsin Department of Health Official

• California's Diabetes Coalition, which includes representatives from the general public, the State DPCP, local health departments, universities, volunteer organizations, pharmaceutical companies, and community-based organizations, has developed evidence-based guidelines, a patient survey, and a model patient record.

Advisory Bodies and Councils

A number of States also have advisory boards and councils that assist with statewide diabetes planning and quality improvement efforts. Whereas coalitions are broad-based, voluntary efforts, advisory bodies are usually smaller, more formalized entities with objectives and structure that are established by law. Advisory bodies and councils include a variety of experts and stakeholder groups such as the American Diabetes Association, State professional associations, and provider organizations, among others.

"The bottom line, no matter how you cut, is that it's about relationships and identifying what people bring to the table. You look at your objectives and those of other agencies or groups and see where it makes sense to work together. Then you help people to understand where the synergy is by finding like goals." — Missouri Department of Health Official

• Florida's Diabetes Advisory Council advises the Governor and the Secretary of the Department of Health on emerging diabetes issues affecting care, treatment, and quality of life.

• The Texas Diabetes Council was created by the Texas legislature in 1983 to promote diabetes prevention and awareness, to work with private and public health care organizations, and advise the legislature on laws needed to further education and health services for people with diabetes.

"The environment is so dynamic and things are changing so quickly – science, policy, reimbursement. We need some way to keep the finger on the pulse and adjust quickly. The Advisory Committee helps us do that." — Minnesota Department of Health Official

Working Across State Agency Lines

State programs often operate in isolation from one another. However, several States have recognized that their diabetes prevention and control program can work with other agencies within State government to reduce diabetes and its complications. This approach can be highly efficient and effective in reaching targeted groups for prevention and disease management.

"In setting up partnerships, think strategically about who might be a good partner. We sat down and thought about how people with diabetes get from A to Z and who is involved in the process. From there we identified all the people, from individual families to large health plans that could have an influence on the process. Then we invited input and involvement that would represent all of those points of view." — California Department of Health Official

• Maryland's Medicaid program adapted the Maryland DPCP's Model for Comprehensive Diabetes Management, paying for a package of preventive services, equipment, and supplies for diabetes care. Although the program was later handed over to Medicaid managed health plans, an independent evaluation found that the diabetes care program saved an average of almost $4,600 a year per program participant.

• Massachusetts' Diabetes Program partnered with the Division of Medical Assistance to implement a patient education and provider training initiative incorporating the Massachusetts Guidelines for Adult Diabetes Care. This involved quality improvement and measurement initiatives related to health outcomes for people with diabetes.

• California worked with the training division of the Department of Motor Vehicles to educate officers in evaluating people who come to the department's attention due to diabetes.

• West Virginia's DPCP has established a worksite health promotion program for State employees that facilitates lifestyle changes to improve the health and self-care practices of people with diabetes.

Program Development Activities

Developing and Complying With Diabetes Guidelines

To close the gap between research and practice, several States are promoting the use of evidence-based clinical guidelines for diabetes care. Many States have adopted existing guidelines established by the National Quality Forum, HEDIS® Comprehensive Diabetes Care Measures or the American Diabetes Association, while others have worked through the process of developing their own.

• Massachusetts DPCP convened a Diabetes Guidelines Work Group to develop the Massachusetts Guidelines for Adult Diabetes Care and accompanying tools for primary care settings.
• Nebraska's Medicaid program has established a Diabetes Subcommittee that is developing consensus guidelines and working with health plans and providers to ensure implementation of the guidelines among those covered by Medicaid.

Data Measurement and Reporting

As Module 2: Data indicated earlier, data measurement and analysis is a fundamental step in quality improvement. State DPCP and others organizations have come together to agree on consensus measures on diabetes quality and used the data to compare quality performance among health plans and providers.

"States are intimidated that there is so much they have to know. We rely on our partners to give us this knowledge. You don't have to know everything you just have to know the right people. The environment may be changing, but the experts aren't." — Minnesota Department of Health Official

• Michigan's DPCP established its Diabetes Core Measures Initiative in collaboration with the Michigan Associate of Health Plans. The measures were developed to ensure that all patients with diabetes receive evidenced-based care.

• The New Jersey DPCP developed and implemented diabetes care performance measures and integrated them into routine clinical practice in several managed care and community health care settings. The performance measures are published in a State newsletter and on the Internet at http://www.state.nj.us/health/fhs/diabnews.htm.

Use of Technology

States are taking advantage of new technologies to improve diabetes care through better communication and more efficient services.

• California created a series of electronic seminars on diabetes-related issues for DPCPs around the country and coalition members throughout the State.

• Maine's Consortium for Clinical Office System Improvement has worked to implement an array of tools for primary care practices aimed at quality improvement, prevention and chronic disease management, including the Cardiovascular & Diabetes Electronic Management System.

• Oklahoma partnered with the University of Oklahoma's Ophthalmology Department to enable rural Oklahomans to receive diabetic retinopathy screening in their own communities using a state-of-the-art fiber optic telemedicine design.

Self-Management/Patient Education

Patient self-management is critical for good diabetes outcomes. Several States have established certification programs for diabetes self-management educators. By requiring this training, States can set a high standard based on the latest evidence-based information. Patient education programs are best conducted in a variety of settings that are easily accessible to target populations, including: churches, neighborhood associations, and other community-based organizations that are well recognized in a community. These programs can be conducted in small groups or one-on-one, based on the identified needs of the population. For more information on diabetes education programs, visit the ADA's Web site at http://www.diabetes.org/education/edustate2.asp.

• Rhode Island created a statewide initiative called My Diabetes Record, which is aimed at improving self-management of diabetes and meeting the national HP2010 objectives for eye care, foot care, HbA1c tests, lipid profiles, and influenza and pneumonia vaccinations. All third-party insurers use this standard tool.

• Utah's DPCP has a State-sponsored certification process for outpatient diabetes self-management programs. The voluntary program uses national guidelines and evaluates diabetes clinical quality improvement.

• Arkansas' Medicaid and DPCP have partnered with the Eli Lilly and Company to provide diabetes self-management education in underserved areas of the State.

Collaboratives

Improving the quality of care for diabetes is a systemic issue. The entire health care system and all its actors need to be mobilized to deal with diabetes. Thus, a number of States established their own statewide collaboratives or have worked with community health centers on the HRSA Health Disparities Collaboratives to achieve diabetes quality improvement.

"Don't get so bogged down in the details that you lose sight of the big picture. Diabetes is the quintessential chronic disease and you need to look at the entire system of care. Simply telling providers to work harder and better will not work if the system is not structured to support them in quality improvement." — California Department of Health Official

• New Mexico was one of several States to participate in the first HRSA Health Disparities Collaborative focused on diabetes. Eleven clinics or practices participated and used an electronic diabetes patient registry to ensure people with diabetes received recommended care with the State health department serving as technical advisor to the participants.

• The State of Washington leads the way in establishing State-based diabetes collaboratives. Since 1999, Washington's three diabetes collaboratives have reached 65 clinical practice teams and accomplished significant clinical improvements, such as reductions in HbA1c levels, cholesterol, and blood pressure. There was also improvement of 35-50 percent in the number of patients who received foot examinations, blood pressure screenings, and cholesterol tests (Daniel, Norman, Davis, et al., 2004).

• Wisconsin developed a unique public-private initiative in conjunction with managed care plans in the State. The Wisconsin Collaborative Diabetes Quality Improvement Project monitors and evaluates plan performance on diabetes measures and works together on quality improvement initiatives. More in-depth information about this initiative is provided in Module 5: Improvement.

Provider Training

Because health care providers are a key element in improving diabetes quality care, many States have actively sought their involvement in developing programs. In addition, States are providing outreach and support to health care professionals as they seek to implement new evidence-based care guidelines.

• New York established three diabetes centers of excellence. Medical centers in the State competed for the recognition and additional funding available for the designated centers of excellence. The centers conduct research and provide health care professionals, providers, and patients with information and resources aimed at improving diabetes prevention and treatment (Cornell, 2003).

• New Hampshire offers an annual statewide multi-track professional training conference targeted to primary care health care professionals, insurers, legislators, podiatrists, school nurses, occupational health nurses, and other health and human service professionals.

• North Carolina provides scholarships for local health department staff to attend the East Carolina University School of Medicine's Clinical Fellowship in Diabetes. The week-long continuing education program is led by a diverse group of faculty who address everything from quality clinical care for diabetes patients to increasing the cultural competencies of providers. The health care professionals who attend are then required to train colleagues in their local communities

State Disease Management Programs

Because States are looking for ways to control costs while maintaining or improving quality in Medicaid, more than 20 States are implementing disease management programs, many of them targeting diabetes (Smith, Ellis, Gifford, et. al., 2002; go to Table 4.1). Medicaid disease management programs seek to increase patient knowledge and self-management skills, improve provider adherence to clinical guidelines, and implement technology to track patients more effectively. Improved care management for diabetes is aimed at decreasing preventable complications, thereby controlling costs and potentially improving long term health outcomes.

"Getting the right people to share your message is the best thing you can do to make sure people listen." — North Carolina Department of Health Official

• Florida's Disease Management Initiative has the longest running Medicaid disease management program in the Nation, addressing a variety of chronic illnesses, including diabetes (Brown and Matthews, 2003).

• Indiana launched the Coordinated Care Management program, a voluntary disease management program for Medicaid patients with diabetes, chronic heart failure, asthma, and other costly conditions for Medicaid. The program will hire 80 new nurse managers over a 2-year period to perform assessments and conduct patient education (U.S. Department of Health and Human Services, 2003b).

• Kentucky's Medicaid Managed Care plan, Passport, identifies members with diabetes through claim review, the nurse advice line, and referrals from doctors. The plan uses patient education and provider interventions to improve self-management and compliance with treatment guidelines. Since its inception in 1999, enrollees are doing better than the national average in monitoring symptoms and controlling the disease, and patient adherence and performance has improved each year of the program (Atkins, 2003).

Dissemination Activities

Raising Awareness Through Public Relations

An important component of addressing diabetes care involves raising awareness. Surprisingly, while there are 13 million diagnosed cases of diabetes in the U.S. in 2002, there were 5.2 million undiagnosed cases of diabetes (CDC, 2003c). If the diabetes goes too long without proper diagnosis, lasting damage to an individual's health can occur. Thus, it is important that the general public and providers be aware of the disease and its symptoms. States use a variety of methods to spread the word about diabetes.

• Wyoming's DPCP published a brochure, "What Wyoming Should Know about Diabetes," and distributed it to 21,000 Medicaid-eligible households and to more than 50,000 other citizens.
• Tennessee's DPCP collaborated with the ADA, the Tennessee Academy of Ophthalmology, and the University of Tennessee Agricultural Extension Service to bring the National Eye Institute's traveling vision exhibit to Tennessee.

"It is vitally important that you include the people who are your target audience in the planning of these programs." — California Department of Health Official

Minority and Rural Outreach

The prevalence of type 2 diabetes is increasing most rapidly among minority populations. In addition, millions of people living in rural area have diabetes, and special attention must be given to ensure they are receiving quality health care. The NHDR reveals that minority racial/ethnic groups and lower socioeconomic groups receive fewer services for diabetes care, and that African Americans and Hispanics have higher hospitalization rates for complications of diabetes (AHRQ, 2003b).

Several States have developed innovative programs to target these groups. A first step in addressing this concern is making patient information available in an understandable format. This could involve using pictorial representations or providing documents in languages other than English. Reaching these groups also involves tailoring the message or targeting the delivery.

"We feel strongly that if we want them to partner, we need to be a partner back. This involves going to meetings they want us to be at and always following through. We take great care with our partners and always put them out front to get credit for their efforts. We want them to see how important they are to this." — Wisconsin Department of Health Official

Removing the Language Barrier

• Florida has made their entire DPCP Web site available in Spanish.
• Washington has 20 self-management educators who are specially trained in delivering diabetes programs in Spanish.

Targeting the Message

• North Carolina partnered with the General Baptist State Convention and the State's Office of Minority Health, to conduct programs for African American congregations throughout the State that focus on awareness, risk factors, complications, and prevention strategies. The program provides educational presentations, workshops, and materials and develops public service announcements to radio stations with a predominantly African American listening audience.
• Minnesota's DPCP coordinates with the Office of Minority Health to address diabetes among minorities. Funds earmarked for reducing disparities in the minority and Native American population pay the salaries of two staff members who work on diabetes efforts targeted at these groups.

Rural Outreach Efforts

• Colorado implemented the Rural Diabetes Project that promotes diabetes preventive practices through a tracking and followup system with private eye care and primary care providers for eye disease screening and blood pressure control. Colorado also coordinates the Buddy System, a network of health professionals that provide diabetes education in hospitals, clinics, and public health agencies. Rural educators are matched with certified diabetes educators for one-on-one consultations.

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