Diabetes management involves more than controlling
blood glucose. Preventing complications is equally important, and diabetic
retinopathy is among the most serious. As we recognize National Diabetes Month,
primary care practices can examine how effectively they identify patients who
need retinal examinations, ensure those examinations are completed, and follow
up on the results.
Care team members such as Medical Assistants (Mas) and Community
Health Workers (CHWs) can play an important role by helping patients overcome
barriers to care and strengthening communication between primary care practices
and eye care specialists.
Diabetic
Retinopathy: The Importance of Early Detection
Diabetic retinopathy is a leading cause of vision loss
and blindness in the United States. Because early stages often have no
symptoms, routine retinal examinations are essential.
Early detection and appropriate treatment can prevent
or delay vision loss. The American Diabetes Association (ADA, 2025) recommends
retinal examinations beginning at diagnosis for adults with type 2 diabetes and
within five years of diagnosis for adults with type 1 diabetes. Follow-up
intervals depend on clinical findings and individual risk.
The Primary Care
Challenge: Closing the Referral Loop
Primary care practices routinely identify patients due
for retinal examinations and refer them to ophthalmologists or optometrists.
However, a completed referral is not a closed referral. Ensuring
referrals result in completed examinations and appropriate follow-up can be
challenging.
Patients may face barriers related to scheduling,
transportation, insurance coverage, or understanding the importance of an
examination when they have no symptoms. Even when examinations are completed,
reports may not reach the primary care practice, leaving the care team without
information needed to determine appropriate follow-up.
Closing the referral loop requires confirming that
examinations are completed, results are received, and recommended follow-up
occurs.
Where Care Team
Members Add Value
MAs and CHWs are well positioned to support this
process as members of the primary care team. Their involvement can begin before
the referral and continue through examination and follow-up.
MAs and CHWs can educate patients about diabetic
retinopathy, assist with scheduling and transportation, address insurance and
language barriers, and reinforce the importance of routine examinations. After
referral, they can confirm appointments, contact patients who miss visits, and
help reschedule.
After examinations, MAs and CHWs can help obtain
reports from eye care professionals and ensure they reach the appropriate
clinical team member. When additional evaluation or treatment is recommended,
CHWs can coordinate appointments and address barriers that might delay care.
Portable
retina cameras offer primary care practices a way to provide point-of-care
retinal screening, providing access to diabetic retinal exams and prevention
vision loss in patients with diabetes. These portable units allow trained
practice staff, including nurses and medical assistants, to capture scans in
about one minute. Screening capability includes diabetic retinopathy, glaucoma,
and other vascular conditions without needing an immediate specialty care
referral. Practices may find this is efficient and cost-effective to close care
gaps.
These responsibilities do not replace clinical
assessment or decision-making. Rather, they support physicians, nurses, and
care managers by helping ensure services are completed and information is
available to guide care.
Implications for
Quality and Value-Based Care
Diabetic retinal examinations are included in several
major quality reporting and value-based payment programs.
Medicare Advantage Star
Ratings. The Diabetes Care – Eye Exam measure
assesses the percentage of eligible Medicare Advantage members with diabetes
who receive recommended retinal examinations. This measure contributes to
Medicare Advantage Star Ratings and may influence financial incentives for
participating primary care practices.
Merit-Based Incentive Payment
System (MIPS). CMS Quality Measure #117, Diabetes
Eye Exam, evaluates appropriate retinal examinations among eligible patients
with diabetes. MIPS also includes Measure #19, Diabetic Retinopathy:
Communication with the Physician Managing Ongoing Diabetes Care, which addresses
communication of retinal findings to the physician managing the patient's
diabetes. Although eye care specialists generally report this measure, it
reinforces the importance of communication between specialists and primary
care.
Medicaid and Commercial
Health Plans. The HEDIS® Eye Exam for Patients with
Diabetes (EED) measure is used in health plan quality reporting and may be
incorporated into Medicaid managed care and commercial payer incentive
programs. Michigan primary care practices participating in payer-sponsored
quality improvement and value-based arrangements may also have diabetic retinal
screening included in their performance measures.
For primary care practices, this creates both clinical
and operational concerns. Patients may have completed their examinations, but
missing reports or incomplete documentation can prevent those services from
being reflected in quality performance.
MAs and CHWs can help close this gap through patient
outreach, referral tracking, and communication with specialty providers,
improving documentation and reducing administrative demands on clinical staff.
Making the Process
Work in Primary Care
Integrating MAs and CHWs into diabetic retinal
screening and follow-up does not necessarily require new infrastructure.
Practices can use existing electronic health records, patient registries, and
care gap reports to identify patients overdue for examinations.
An effective workflow identifies patients needing
examinations, assigns outreach and referral responsibilities, and tracks
receipt of results. Incorporating standing orders so MAs and CHWs can support
these activities is efficient and allows clinicians review findings and
determine next steps.
Clearly defined responsibilities and communication
pathways are essential. MAs and CHWs need to know when and how to escalate
concerns, particularly when patients report new vision changes, experience
difficulty obtaining specialty care, or require additional assistance.
For practices with limited care management resources,
integrating MAs and CHWs into this
process can expand care team capacity and improve coordination without adding
to the clinical workload.
Moving Beyond the
Referral
Preventing avoidable vision loss requires more than
identifying patients who need retinal examinations. It requires coordinated
care that ensures examinations are completed, findings are communicated, and
recommended follow-up occurs.
Integrating MAs and CHWs into this process strengthens
primary care's ability to prevent complications, improve quality performance,
and make more effective use of care team resources. National Diabetes Month
offers an opportunity to look beyond whether referrals are made and consider
what happens afterward.
References
American Diabetes Association Professional Practice Committee. (2025).
Retinopathy, neuropathy, and foot care: Standards of care in diabetes—2025. Diabetes
Care, 48(Supplement 1), S252–S265.
Centers for Medicare & Medicaid Services. (2026). 2027 Medicare
Advantage Star Ratings fact sheet.
Centers for Medicare & Medicaid Services. (2025). 2026 Quality
Measures (117, 19). Measures and Activities - QPP.
National Committee for Quality Assurance. (2026). HEDIS® measure
description: Eye exam for patients with diabetes.
