A. Appropriate and Timely Treatment

Dashboard Data Measure: A1C testing done in the last 12 months or 6 months if A1C ≥ 9.

Blood glucose testing is critical for assisting providers in monitoring responses to treatment and making treatment decisions with patients. It also assists patients with understanding the influence of lifestyle and medications on their glucose. We promote use of A1C testing every 3 months for patients with A1C above goal, and A1C testing every 6 months for patients who are at their A1C goal per the American Diabetes Association (ADA) guidelines.¹² While A1C testing is useful, we promote use of more frequent blood glucose monitoring paired with at least monthly follow-up of these readings with a clinical care team member for further medication and lifestyle optimization to more rapidly improve A1C levels. This recommendation is based on data showing that patients with more frequent follow-up have greater improvements in A1C,^13-15 including in the prior Medicaid-funded statewide Diabetes Quality Improvement Project and prior waves of this AHEAD project. Following, we describe self-monitored blood glucose (SMBG) options for patients.

Self-Monitoring of Blood Glucose: While routine self-monitoring of blood glucose (SMBG) may not provide benefit for all individuals with type 2 diabetes managed with oral medications alone, evidence suggests that periodic, structured SMBG combined with appropriate clinical decision support can improve A1C levels in individuals who are not achieving glycemic targets.¹⁶ Consider patient-owned continuous glucose monitors (CGMs) if the patient takes at least one injection of insulin a day, has a history of documented hypoglycemia, or is above A1C target for age and comorbid medical conditions. CGM can be considered for other patients if cost and insurance coverage are not a barrier. A CGM automatically monitors glucose levels every 1-5 minutes and sends results to a smartphone or reader. Some CGMs need to be scanned every 8 hours or there will be gaps in data, while others do not need to be manually scanned. When prescribing SMBG or CGM, ensure that patients receive ongoing instruction and regular evaluation of technique, results, and their ability to use data to adjust behaviors and glucose lowering therapies. Recently expanded Medicare coverage of CGMs includes people with type 2 diabetes who are taking at least one injection of insulin a day as well as beneficiaries who are not taking insulin but have a history of hypoglycemia. Medicare requires a prior authorization and many times the order needs to be placed as durable medical equipment (DME), although it does vary depending on the plan. For Medicaid enrollees, prescriptions are sent directly to the pharmacy without prior authorization. Eligibility criteria for other insurers can be searched online at pro.diabeteswise.org/prescriptions.

Dashboard Data Measures: % of adults with diabetes and A1C ≥ 9 on insulin; % of adults with diabetes and A1C ≥ 9 on newer medications (GLP1-agonists and SGLT2 inhibitors); % of adults with diabetes and A1C ≥ 9 on a specific number of medications.

Medication intensification (starting or increasing a diabetes medication), medication adherence (or medication taking), and lifestyle change are Key Drivers of improved A1C control.¹² Lifestyle programs such as diabetes self-management education and support, medical nutrition therapy, and weight management programs are important evidence-based referrals for patients with diabetes as part of an approach to improve their blood glucose control. In addition, the American Diabetes Association 2026 Standards of Care recommends to consider metabolic surgery as a weight and glycemic management approach in people with diabetes with a BMI ≥ 30.0 kg/m2 (or ≥ 27.5 kg/m2 in Asian American individuals) who are otherwise good surgical candidates.¹² We discuss lifestyle approaches further under Key Driver D.

Following, we provide selected medication management resources related to medication intensification, medication taking or adherence, starting people on insulin, and hypoglycemia and deintensification to ensure attention to safety concerns. The treatment algorithms demonstrate the importance of using newer medications which have been shown to improve cardiovascular and kidney outcomes.