Your Practice Transformation Companion

Tuesday, November 19, 2013

November: National Diabetes Month

Guest Blogger: Laurie Smith, LMSW, CDE MedNetOne

Happy Fall! We've just passed Halloween, Thanksgiving is right around the corner, and the Christmas season is upon us. It is also National Diabetes Month, a time to reflect on a disease that (by CDC estimates) is projected to affect one in three U.S. adults by the year 2050. 

While the American Diabetes Association (ADA) estimates that nearly 26 million Americans are living with diabetes, it also estimates that nearly 25% of those persons remain undiagnosed. The ADA also estimates that another 79 million people are now pre-diabetic. Therefore, the danger (and perhaps opportunity) of this disease lies at the intersection of early detection and treatment.

The concept of a Patient-Centered Medical Home (PCMH) provides an ideal framework in which to transform the way in which providers and patients engage in the prevention and treatment of chronic illnesses such as diabetes. Through this physician-led team-based approach to healthcare, patients are now receiving increased access to providers (RelayHealth online patient portal, extended hours access, etc.) and their team. Evidence-based care (annual depression screenings, preventative testing, etc.) is being delivered in more coordinated and effective ways at reduced costs and information technology is being used to better manage the health of PCMH patient populations.

Are you using Wellcentive to alert you to place reminder calls to your diabetic population to obtain their yearly foot exam? 6mth A1c? Other lab values? This is a tool available to us that can both increase our HEDIS scores and improve patient health and outcomes, not to mention patient satisfaction.

Another key feature of the Patient-Centered Medical Home is the use of a Care Manager. A Care Manager can assist the PCMH team with diabetes management in a number of ways: a coaching call between visits to address potential barriers to adherence; further disease education and/or clarification of PCP’s orders; goal-setting and problem-solving related to diet and exercise; closer tracking of referrals to specialty providers; brief intervention for depression and/or anxiety; etc. 

With the costs of treatment for diabetes in the US estimated at $245 billion in 2012, one of the most important strategies to combat this disease is prevention. The Patient-Centered Medical Home and use of a Care Manager are essential tools in this approach. Through targeted population-based health management, PCMH teams can utilize patient registries for early detection of this disease through identifying patients exhibiting other risk factors (such as family history, ethnicity, obesity, hypertension, hypercholesterolemia, etc.) and screening them earlier and at regular interval. Beginning to identify and treat pre-diabetes is key to reducing costs and improving overall treatment outcomes.

Finally, it is important to remember that the most beneficial prevention and treatment for diabetes can be seen through lifestyle change. Increasing our steps per day and reducing our portions are small steps that each of us can make on a daily basis to prevent diabetes. Sharing knowledge and encouraging our patients to set small, achievable goals can result in improved patient satisfaction. Reaching out to families and caregivers and getting involved in our community to promote healthy lifestyle intervention sends a message to our patients that we are as committed to combating this disease as they are.

For further information see the links below:
·       Visit the National Diabetes Education Program at for more information.
·       Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes helps people assess their risk for developing type 2 diabetes and implement a program to prevent or delay the onset of the disease. This resource includes an activity tracker and a fat and calorie counter.
·       Practice Transformation for Physicians and Health Care Teams is designed for health care professionals and administrators who want to change systems of health care delivery around diabetes.
MedNetOne – PCMH information:

Monday, November 4, 2013

Are You Ready for 2015?

It’s that time of year again. Here in Michigan, autumn is in the air, the leaves are changing, the weather is turning colder and we are readying our homes and cars for winter. As our lives change with the seasons, so does health care. The title of this blog, “Are you ready for 2015?” is not a typographical error. In order to be ready for the future, we have to prepare in the present.

In July of this year, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would update current payment policies and rates for services furnished under the Medicare Physician Fee Schedule on or after January 1, 2014. The proposed rule in its entirety can be found at If the proposed rule becomes a final rule, physicians will be able to bill for managing select Medicare patients’ complex chronic care management needs. This is a positive step toward rewarding physician practices that provide chronic care services, especially those patients with multiple conditions and needs requiring additional resources. CMS is delaying payment till January 2015 because it knows physician practices will need the extra time to develop, manage and put the systems and processes in place to meet the standards.

The scope of services in the proposed rule may include some of the following:
§  Patient access to a health care provider  24/7 for urgent chronic care needs with access to the patient’s full electronic medical record even after the office closes;
§  Creation of a comprehensive care plan to address all aspects of a person’s health, congruent with the patient’s choices and values;
§  Management of care transitions including  referrals to other clinicians and timely follow up care after discharge from an ER visit, inpatient stay or skilled nursing facility, including the electronic exchange of  information;
§  Coordination of community based referrals; and
§  Utilizing secure messaging or other non face-to-face consultation methods with the patient.

Many of the proposed standards for providing complex chronic care management services are tied to the most recent Health and Human Services regulatory standards for Meaningful Use. The EHR must be integrated into the practice to support access to care, care coordination, care management and communication. For physician practices that are operating as patient centered medical homes (PCMH), there are suggestions to consider a nationally recognized PCMH practice as one means of meeting the care coordination standards for complex chronic care management services.  

Practice Transformation Institute (PTI) is a southeast Michigan leader in helping primary care practice teams transform to a patient centered model of care. PTI has classes available to help your practice attain the proposed changes coming in 2015. To meet the needs of national PCMH programs, PTI has trained coaches for NCQA’s PCMH Recognition program and URAC PCMH Certified Auditors for their Achievement program.

PTI is ready. Are you?