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Health Care Providers Improve Diabetes Care for Patients

Providers from across New York State share their stories about earning national recognition for providing excellent diabetes care from the National Committee for Quality Assurance (NCQA) or Bridges to Excellence (BTE) programs with NYSHealth support.

Provider Stories
 

Rohit Bhalla, M.D.
Organization: Montefiore Medical Center
Location: Bronx, NY
Number of Patients: Medium

Dr. Bhalla discusses how BTE recognition has allowed providers to measure their performance and focus on evidence-based standards. 

In your view, what are the most important measurements of quality of care required by the BTE Diabetes Care Recognition Program?

All of the parameters assessed by the BTE Diabetes Care Recognition Program are important, as they follow evidence-based guidelines for diabetes mellitus care. In preventing cardiovascular and end-organ disease, the “ABC’s” of HgbA1c, blood pressure, and cholesterol control are of primary importance.

How will BTE recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?

The BTE recognition has been a significant achievement for Montefiore. The recognition allowed us to clearly assess and validate our performance. It has strengthened the commitment of Montefiore physicians to deliver superior diabetes care. We are striving to maintain and improve this performance and hope to ultimately see reductions in rates of kidney disease, heart attack, and stroke.

Did compiling the data for BTE’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?

Montefiore built upon its existing electronic clinical information and medical record systems to facilitate data capture, and leveraged the capabilities of its performance improvement and data analysis groups for BTE evaluation purposes.

In what ways did you or Montefiore Medical Center have to adjust policies or practices in order to achieve BTE recognition?

We did not need to make specific adjustments, as the BTE data submission requirements aligned well with our data requirements for creating provider performance reports.

In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?

These programs allow practices to focus and prioritize evidence-based care standards and validate efforts practices make to improve quality of care. As health care is complex and providers are focused on individual patients, there are few opportunities to take a step back to assess how a practice or delivery system is performing as a whole. The usage of evidence-based performance measures, standardized specifications, and external review allows for a rigorous assessment of processes of care, much as board certification serves as a structural measure. Public recognition of excellence in care promotes provider engagement in quality improvement, patient decision making, and payer insight into the value of services provided.

 

Nancy Brennan-Jordan, F.N.
Organization: Seton Health
Location: Troy, NY
Number of Patients: Medium

Certified diabetes educator and family nurse practitioner Nancy Brennan-Jordan explains how NCQA recognition creates momentum for excellent care among providers and bolsters patient confidence.

In your view, what are the most important measurements of quality care required by the NCQA Diabetes Recognition Program?

All indicators are important and have value. I am delighted that they have included smoking cessation as one of their key indicators.

How will NCQA recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?

NCQA recognition has been achieved by seven of our Seton Health physicians. It is setting the standard and creating momentum for more providers to apply.

Did compiling the data for NCQA’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?

Collecting the data was quite challenging. We do not have an EMR. We do utilize flow sheets, but the data collection was very time intensive.

In what ways did you or Seton Health have to adjust its policies or practices in order to achieve NCQA recognition?

There were no policy changes at this time.

In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?

The overall value of recognition programs for diabetes care is that it helps to validate the good work of our provider teams and serves as a role model for other providers within our system. It also communicates to patients that they are receiving care from a health system which strives for excellence. It enhances the patient-provider relationship.

Any final thoughts?

Our NCQA DRP (Diabetes Recognition Program) was successful because of our Defy Diabetes nurse champion program. We believe that nurses are the glue to a practice and we empowered 14 Defy Diabetes nurse champions within our system. They received three in-services, during which we updated them on the ADA (American Diabetes Association) guidelines and best practices. The nurse champions coordinated the team approach and have a sustainable presence within the practice for continued quality improvement.

 

Brenda Davies-Wait, D.O.
Organization: Bassett Healthcare Network
Location: Cooperstown, NY
Number of Patients: Medium

Dr. Davies-Wait discusses the importance of NCQA recognition, including the benefits of hard patient data and of learning where providers can make improvements.

In your view, what are the most important measurements of quality care required by the NCQA Diabetes Recognition Program?

The HgA1C is the most important measurement. At this point, we know that one of the best ways to assess our management of our diabetic patients is the HgA1C.  However, I do think we need to be careful when we state that good control is for those less than 7%; this could be inaccurate in a practice that is mostly older as most of us are comfortable with HgA1C of 7.5%.

How will NCQA recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?

Thinking how you are doing versus knowing are two very different things. The recognition process allows us to see how we are doing with hard data. With the data, we can then make changes in our process. For example, we have made changes to improve our foot exam assessments in the following ways: We now place a footprint on the progress note when diabetic patients come in for a visit to remind the provider to do a foot exam; we will be training our nurses to do foot exams; we also reviewed, as a group, the standards of care and ways we may be able to continue to educate our patients.

Did compiling the data for NCQA’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?

With the EMR, patient information is current. We already had the EMR, so there was no change in our organization.

In what ways did you or Bassett Healthcare Network have to adjust policies or practices in order to achieve NCQA recognition?

We did not have to adjust policies or practices.

In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?

Being recognized allows patients and other providers to know we strive for perfect care. Going through recognition allows providers to assess how they are doing and see areas that they may need to improve on.

Any final thoughts?

I cannot stress how important it is to know where you stand in your practice so you can always make a positive change.

 

Allen L. Fein, M.D.
Organization: Family Practice
Location: Southampton, NY
Number of Patients: Small

Dr. Fein, a family practice physician who himself has diabetes, describes how NCQA recognition changed how he cares for patients with diabetes.

In your view, what are the most important measurements of quality care required by the NCQA Diabetes Recognition Program?

The HgbA1C is a very important and effective measurement that reliably informs the patient and the physician about the bottom-line of glucose control for the previous few months. Too often patients “behave” for a few days before office visits and lab tests, to quickly but temporarily improve their weight, blood pressure, and fasting blood glucose, for the record! The patient’s blood pressure is also very important because it has been established that blood pressure control is more important than glucose control, in the long term for patients with diabetes.

How will NCQA recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?

After focusing repeatedly on the targets of the NCQA program, the physician should more easily seek out and implement the targets in diabetic patients. Patients with diabetes make multiple visits to a physician, and while dealing with the myriad of their presenting complaints, it is important to step back and efficiently check on the “big picture” every 6 – 12 months. Preparing for the NCQA recognition helps the physician cement good habits. It is not usually the patient who is going to initiate such diabetes quality care overviews!

Diabetes is not the kind of disease where patients come running back to thank the physician for great outcomes, because the complications of diabetes are somewhere out in the vague future. Efforts to get patients to meet targets usually require much effort at dieting, active exercise, smoking cessation, and often new medications. These are not simple, permanent, quick fixes that patients want and often expect.

Some patients will be happy to share stories about having more energy and having to spend less time day and night running to the bathroom, and many will be happy to reach their target numbers (BP, HgbA1C, LDL, etc). I believe that as we stay with our diabetic patients over the decades, and see that they have avoided problems, while their friends and family end up with serious illnesses, there will be a significant delayed gratification enjoyed by all.

Did compiling the data for NCQA’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?

Every 6 -12 months, I am now making the effort to include in the patient’s progress notes, a review of where the patient stands vis-a-vis the target numbers, and to determine changes needed. It is too easy to forget about these specific targets while putting out the many fires diabetic patients are always coming in and out of the office and hospital with. Thanks to a hospital/government initiative, we plan to go paperless (NextGen) in the near future, which should make thing easier for us to manage our diabetic patients.

In what ways did you have to adjust policies or practices in order to achieve NCQA recognition?

Initially, I reviewed my diabetic patient medical records, and contrary to what I had expected, it was clear that I was quite far from meeting NCQA goals. Being a diabetic myself, I was familiar with and supported such target goals. I had thought that my patients were getting very good care, so this was quite an eye-opener for my staff and to me personally.

My office subsequently made diabetes care a priority. All diabetic charts were pulled and each chart reviewed. We basically badgered all our diabetic patients to come in for focused diabetic care visits. Those patients who were non-compliant were called and sent letters letting them know that they were overdue for a visit, and were advised to schedule an appointment in order to maintain their active patient status with me. We then evaluated all such patients for the target goals, and made the appropriate interventions, including timely follow-up with us.

A lot of effort was made assisting patients to set up visits with specialists for dilated eye examinations. We learned that the requirement by NCQA to have in the patient record written proof of dilated eye exam, rather than a simple statement from the patient attesting to such examination, was worthwhile, in that many of our patients who had claimed to have had such important examinations done, actually had not had them done! We felt that there may have been a little impatience from specialists about all our phone calls, but after personally speaking with the specialists about the NCQA program, and the importance of getting the dilated examinations done, there was good cooperation.


In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?

The preparative groundwork done by my office staff and by myself was eye-opening. We were quite surprised as to how many of our patients with diabetes were not even being evaluated for the diabetic targets, and how many of those tested were not at target. We were surprised that many patients with diabetes had been lost to follow-up. The teaching materials provided to me by the NCQA program were excellent, up to date, and also provided free accredited CME. It was very satisfying to my office staff, my patients, and myself, to see the fruits of our labor a year later, when it was clear that we were well on top of the diabetic patient targets. In the end, we breezed through the NCQA recognition requirements.

While there was a significant cost to the practice in participating with the NCQA program, from many uncompensated hours of reviewing charts and collecting the data, there were also many office visits generated that otherwise would have not occurred. There was also a generosity of help and encouragement from the New York Academy of Family Physicians, and even an offer to come to my office to help go through the charts to collect the data,  a service which we never ended up needing, once we realized how simple and easy it was to enter the data into their flow-chart.

I have since led a CME workshop on diabetes with my peers (which paid me $500!), and in January, 2011, I will lead a module on diabetes for Family Physicians (which will give me two free nights at a ski resort!), so there have indeed been personal unexpected gratifications to the many hours invested in beefing up my diabetes skills, beyond earning the certificate and having well cared for patients.

Subsequently to my earning the NCQA recognition, there have been a few articles and announcements in the local press about this. A few patients have since congratulated me, but so far, there has not been a stampede of new diabetic patients coming through my door! I am unaware of any excitement by the health insurance plans that I work with, to inform their members about this accomplishment, nor am I aware of any financial reward or incentive by any of the insurance companies for such NCQA recognition. I certainly didn’t do this for the money anyway; as a physician with diabetes, it was personally important for me to participate in this valuable program. I had looked into this recognition a couple of years ago, but was turned off by the high application fee. Now, thanks to grants, signing on to this program through the New York Academy of Family Physicians did not cost me anything.

Any final thoughts?

I recommend that my colleagues join in participating in this valuable and rewarding initiative.

 

Douglas Rahner, M.D
Organization: Family Health Network
Location: Cincinnatus, NY
Number of Patients: Large

Dr. Rahner says NCQA recognition helped create friendly competition among providers and is valuable for publicly recognizing those who are providing quality care.

In your view, what are the most important measurements of quality care required by the NCQA Diabetes Recognition Program?

I believe blood sugar control (as determined by HbA1c <7% and >9%) and blood pressure control (<130/80 mm Hg and ≥ 140/90 mm Hg) are the most important measurements.

How will NCQA recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?

NCQA recognition has enabled better care for patients with diabetes because it allowed the organization to develop policy and procedures to ensure the care was occurring. Also, the measures allowed providers to see actual statistics demonstrating improved diabetes care. NCQA recognition supported the processes that were being followed in the Chronic Care Model.

Did compiling the data for NCQA’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?

The organization was already documenting  and tracking the diabetes clinical information through a Diabetes Registry called Patient Electronic Care System (PECS).

In what ways did you or Family Health Network have to adjust its policies or practices in order to achieve NCQA recognition?

It was not an adjustment, but a development of policy and procedure to get patients with diabetes an annual dilated eye exam. The organization needed to develop a process and streamline communications with ophthalmologists in the community.

In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?

Prior to applying for NCQA DRP (Diabetes Recognition Program), the organization was following a majority of the measures from the Chronic Care Model and had adopted clinical guidelines from the American Diabetes Association Standards of Care. NCQA recognition allowed the organization to make quality improvement to the measures and add the new measure needed to obtain NCQA recognition. The recognition just reinforces the progress the organization has made to address the health care given to patients with diabetes.

Any final thoughts?

It engendered a little bit of competition between providers, which, overall, is helpful in improving performance. It also allowed the organization to formally recognize the providers who have contributed to developing the diabetes program.

The video below takes an in-depth look at NYSHealth's collaboration with grantee partners to reach this goal, as well as other health care providers who underwent the recognition process.

About this Initiative
 

At the close of 2013, NYSHealth surpassed its five-year goal of helping 3,000 primary care providers attain recognition from the NCQA and BTE diabetes programs, which is an indicator that clinicians are delivering the best care and achieving good outcomes for patients. By targeting 3,000 doctors, approximately 25% of the 11,000 primary care physicians in New York State, NYSHealth expected to set a new standard of care that will lead to a tangible increase in the number of people with controlled diabetes, a decrease in hospitalization rates for people with diabetes, and a decrease in the number of emergency room visits related to diabetes. New York State now has 3,100 providers in solo and group practices, outpatient departments, and community health centers who have attained diabetes recognition with support from the Foundation and its grantee partners.

Providers applied for funds to help achieve recognition through NYSHealth’s Meeting the Mark: Achieving Excellence in Diabetes Care request for proposals (RFP). Through this RFP, NYSHealth awarded $2,500 per physician who achieved recognition.

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