New York Diabetes Leadership Initiative Demonstration Project
Submission Date: December 2013
Entry Type: Case Study
State/Territory Submitted on the Behalf of: New York
States/Territories Involved: New York
Domain Addressed:Community-Clinical Linkages, Health Systems Strategies
Public Health Issue:The prevalence of diagnosed diabetes in New York adults increased from 5.7% to 8.9% between 1999 and 2010. Diabetes is a public health priority since much of the illness it causes is preventable. Early detection and management of major diabetes complications, including diabetic kidney disease and neuropathy, can slow their progression and improve quality of life for people with diabetes.
Project Objectives:- Increase awareness among members of the healthcare team regarding needed services for their patients with diabetes, especially those services related to DKD and diabetic neuropathy
- Increase referrals to DSME programs for patients with diabetes and track their clinical measures
The New York State Department of Health (NYSDOH) project engaged a large community health system network, Hudson River HealthCare (HRHC) at three of their federally qualified health center (FQHCs) sites to develop and implement a curriculum for community health workers focused on diabetic kidney disease (DKD) and the importance of an annual comprehensive foot exam for persons with diabetes. The partner had a long history of working on quality improvement initiatives, including one focused on chronic kidney disease, had staff experienced with implementing quality improvement projects and had a commitment to serving the vulnerable and under-served of Hudson Valley and Long Island. Funding was provided to NYSDOH through the Diabetes Leadership Initiative spearheaded by NACDD with support from the Boehringer Ingelheim and Eli Lilly Company alliance, as well as to additional demonstration project states.
Project implementation strategies included training providers; developing a new curriculum to educate people with diabetes; diabetes community education; and clinical information system modifications to support providers care of patients with diabetes.
Data/Other Information Collected:The FQHCs received funding to support data collection; data was supplied to NYSDOH as aggregated baseline data and quarterly data. Each data submission included number of partners, providers and patients reached by the project, and these measures for people with diabetes, based on ADA Standards of Medical Care in Diabetes-2012 which were in place at the time the project began:
- A1c <8%*
- BP <130/80 mm Hg
- LDL<100mgdL
- Non-smoker
- Annual test for urine albumin excretion (UACR)
- Annual estimated glomerular filtration rate (eGFR)
- ACEI/ARB prescription for nephropathy
- Annual foot exam
- Medical Nutrition Therapy (MNT) referral as needed
- Renal specialist referral when eGFR<30; uncertain etiology or difficult management of kidney disease
[* ADA standards state “Less-stringent A1C goals (such as <8%) may be appropriate for patients with a history of…advanced microvascular or macrovascular complications”]
The evaluation methodology used a rolling annual data analysis time frame – each quarterly data submission included the previous 12 months of aggregated data. The data on care management were gathered primarily to give partner clinics a tool for monitoring changes resulting from project efforts and represent a point-in-time. Factors affecting interpretation of the data included the addition of a site after baseline and statistical phenomenon such as seasonal variation and regression toward the mean.
Impact/Accomplishments:- The project worked with 62 health care providers and reached over 6,400 people living with diabetes by Q7 of the project.
- The health centers reported implementation of the following health systems changes (see complete list in project summary at: -to be inserted when available):–The partner instituted new, half-hour group diabetes visits for up to six patients at a time led by a registered dietitian or a certified diabetes educator. Patients are invited to attend following an appointment with their provider. A DKD curriculum developed by the partner for community health workers (CHWs) provides an organized, educational resource for the group visits. The NYSDOH developed and implemented two CHW trainings, one in each health center site, to enhance the skills of CHWs in DKD and diabetes education. The partner finds that group visits are an effective and efficient way to provide education and support to diabetes patients and they promise to have a lasting impact on diabetes care in partner sites.
— The partner aligned project efforts with their work already in progress on National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home Recognition and the Diabetes Recognition Program. They credit the project data collection requirements and the increased provider awareness of care management standards, with helping them to reach these goals.
— Newly-developed reports helped providers identify patients who had not participated in DSME who were then contacted by staff to encourage attendance at classes held at the clinic.
— NYSDOH worked with the partner to implement Community Education Days focused on diabetes and DKD in the two communities where the health centers are located. Topics covered include diabetes management, nutrition, and information about complications such as diabetic kidney disease, foot exams and foot care. Several of the sessions were offered in other languages, Spanish and Creole. HRHC also collaborated with Vassar Hospital, Dutchess County Department of Health, and the Institute for Family Health (an FQHC) to conduct additional Community Education Days.
- Among the patients with diabetes, health centers reported the following improvements in diabetes care management measures between baseline and Q7: Both the UACR measure and the combined UACR/eGFR measure increased. The greatest improvement occurred in receipt of a diabetic foot exam which increased by nearly 140%.
- Among the patients with diabetes and stage 3 or 4 DKD, health centers reported the following improvements in diabetes care management measures between baseline and Q7: Referrals to a nephrologist rose slightly; percentage of patients receiving a referral for MNT increased by a factor of six. The percentage of non-smokers and of patients with LDL cholesterol <100mg/dL remained at or above national benchmark rates for adults with diabetes throughout the project.
When expanding the initial work to other clinic sites, NYSDOH used several criteria to identify higher priority sites and readiness: 1)no recent clinic leadership changes, 2) well-established internal champion and/or physician, perhaps already working on quality improvement but not currently overloaded with ongoing QI programs, 3)well-organized and managed site.
Key learnings states, partners and NACDD took from the initiative which will apply to future health systems change projects include:
- Establishing a functional team is very important to health systems change – physicians, nurses, registered dietitians, patient care coordinators, community health workers, leadership staff, IT staff and vendors – all must be involved in planning and executing health systems changes for the most efficient and effective result.
- Public health should enter systems-change partnerships with an eye to sustaining and extending expected successes and health system improvements. This means an upfront assessment of partner’s readiness and potential for sustaining and extending changes.
- Every level in a clinic setting is essential to implementing systems changes. All health center staff needs to know how their work relates to quality improvement and how it supports patient management.
- Relate health systems change project to meaningful use, use data to correct system design and collect data with the intent to improve the system. Most DLI project measures partners reported are aligned with meaningful use measures.
- Align health systems quality improvement projects with reporting requirements to increase motivation of providers to participate.
- Data collection is vital since ongoing review of the data can drive system improvements
Diabetes
State Contact Information:
New York
Laura Shea, RN, MA, Clinical Practice Coordinator, Diabetes Prevention and Control Program
New York State Department of Health
518-408-5142
las11@health.state.ny.us