Michigan Diabetes Leadership Initiative Demonstration Project
Submission Date: December 2013
Entry Type: Case Study
State/Territory Submitted on the Behalf of: Michigan
States/Territories Involved: Michigan
Domain Addressed:Health Systems Strategies
Public Health Issue:The prevalence of diagnosed diabetes in Michigan adults increased from 5.4% to 10.1% between 1999 and 2010. Diabetes is a public health priority since complications from the disease are largely preventable. Early detection and management of major diabetes complications, including kidney and cardiovascular disease and retinopathy, can slow their progression and improve quality of life for people with diabetes.
Project Objectives:To improve the evaluation of DKD and retinopathy among patients of a major health system through integration of a protocol into the DSME assessment already being conducted by a diabetes educator
To integrate DKD patient assessment and education into the role of patient care coordinators and increase referrals to nephrologists and medical nutrition therapy, as appropriate
Program Action:The Michigan Department of Community Health (MDCH) engaged two partners, a major health system (diabetes self-management education or DSME partner) and a federally qualified health center (FQHC partner). The DSME partner’s primary intervention strategy focused on integrating a protocol for diabetic kidney disease (DKD) and retinopathy evaluation into the DSME program assessment conducted by a diabetes educator. One certified health system DSME program agreed to participate and that program encompassed 5 sites and 9 staff members. The MDCH role as certifier of DSME programs throughout the state provided good potential for extending the success of the demonstration project to additional program sites. The FQHC partner had a history of working on diabetes quality improvement projects and employed patient care coordinators to meet with all patients with diabetes for assessment and discussion of kidney health and retinopathy.
Under an expanded scope of work the Michigan project also asked partners to include a focus on an additional complication of diabetes to complement initial attention to DKD. Michigan chose retinopathy using the annual dilated eye exam as the evaluation measure. Both partners committed to sustaining the DLI protocol and health system changes made.
Data/Other Information Collected:The health system and FQHC partners received funding to support data collection; data was supplied to MDCH as aggregated baseline and quarterly data and was analyzed separately for the two partners. 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 eye exam
- 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 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.
Impact/Accomplishments:- The project reached over 1,200 people living with diabetes by Q7 of the project.
- Clinics and health centers reported implementation of the following health systems changes (complete list in the project summary at: to be inserted when final project summary is posted)- The DSME partner staff and a physician champion developed a standing order process, mirroring an existing one for medical assistants, to allow dietitians and nurses to arrange a kidney screening test (microalbuminuria or urine albumin-to-creatinine ratio and/or estimated glomerular filtration rate or eGFR) as patients required it. This process is now incorporated in their primary care standards for “no missed opportunity” a standard which promotes keeping primary care patients up-to-date in recommended tests for disease prevention and chronic care management. Staff checks a registry at each primary care encounter and also now at each DSME visit, and orders any test due in the next 30 days or past due. This change will be implemented throughout the partner primary care sites.
– Patient care coordinators at the FQHC partner site were introduced shortly before the start of the project and now meet with all patients with diagnosed diabetes for education on preventing and managing DKD and to arrange MNT and nephrology referrals as appropriate. The DLI project helped the FQHC define the role of the coordinators as a focus on diabetes care and complications. Coordinators identify and call patients who have not been seen for over 6 months to arrange appointments for needed follow-up. This partner increased the number of patient care coordinators during the course of the project and plans to extend the use of patient care coordinators to management of patients with hypertension.
- The DSME partner reported the following improvements between baseline and Q7:- Receipt of a UACR test improved by 130% and receipt of both UACR/eGFR improved by 100% for patients with diabetes.
– Among patients with stage 3 or 4 DKD five out of six measures improved; referrals to a nephrologist increased substantially. The percentage of patients who achieved blood pressure control of < 130/80 increased and the percentage of nonsmokers rose slightly.
- The FQHC partner reported the following improvements between baseline and Q7:- The percentage of patients with diabetes who received nephrology screening increased as well as the percentage of patients receiving a dilated eye exam, which increased substantially.
– Among patients with stage 3 or 4 DKD referrals to MNT increased; the percentage of patients with A1c <8% and achievement of LDL cholesterol <100mg/d increased by 33% and 39% respectively.
Look for simple points of entry into the system. Seemingly minor health system changes can have significant impact.
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 clinic 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:
MI
Anne Esdale, MPH, Public Health Consultant (esdalea@michigan.gov) / Dawn Crane, MS, RN, ACNS-BC, CDE, DSMT Certification Program Coordinator/Nurse Consultant (craned@michigan.gov)
Michigan Department of Community Health
517-335-6936 (Esdale) 517-335-9504 (Crane)
esdalea@michigan.gov