In this section, we provide resources related to blood sugar monitoring which is critical to determining the appropriate follow-up schedule and treatment.
In addition, we provide key resources on effective medication treatment and medication adherence which are critical to improving A1C control. Additional strategies and resources which promote appropriate and timely treatment will be addressed in future key driver sections due to overlap in strategies which address multiple key drivers.
A1: Blood Sugar Monitoring
Dashboard Data Measure: A1C testing done in the last 12 months or 6 months if A1C > 9.
Blood sugar 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 sugars. 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 as per the American Diabetes Association (ADA) guidelines.14
While A1C testing is useful, we promote use of more frequent blood sugar 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,15-17 including in the prior Medicaid-funded statewide Diabetes Quality Improvement Project. Following, we describe self-monitored blood glucose (SMBG) options for patients.
Self-Monitoring of Blood Glucose. While SMBG in people with type 2 diabetes on oral diabetes medications alone has not been proven to be beneficial for all people with type 2 diabetes, a comprehensive approach that utilizes periodic structured SMBG with decision support has been shown to improve A1C levels in people who are not at target.18 Consider patient-owned continuous glucose monitors (CGM) if the patient takes at least one injection of insulin a day, has a history of documented hypoglycemia, or is above the A1C target for age and comorbid medical conditions. CGM can be considered for other patients if cost and insurance coverage are not a barrier. CGM automatically monitors blood glucose levels every 1-5 minutes and sends results to smartphone or reader throughout the day without needing to do anything and sends results to a smartphone every few minutes. 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 1 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) supply, although it does vary depending on plan. For Medicaid enrollees, prescriptions are sent directly to pharmacy without prior authorization.
Other insurers eligibility can be searched online here.
Medicaid patients are eligible for CGM if they have any diagnosis of diabetes, including type 1 diabetes or type 2 diabetes.
A1.1: Table of Indications, Frequency, and Method of Glucose Monitoring
A1.2: Blood Glucose Log
This is a two-week log, which includes before and after meal-time slots, a medication log, and a notes section. It is available from the American Diabetes Association.
A1.3: American Association of Diabetes Educators Self-Monitoring Using Meters in Type 2
Additional SMBG tools that can be used with patients.
A1.4: American Diabetes Association DiabetesPro
Search the ADA Education Library’s free registered user content for worksheets including: All About Blood Glucose, Blood Glucose Log, Tracking Blood Glucose, Checking Blood Glucose, and Low Blood Glucose.
A1.5: Optimizing the Telehealth Diabetes Visit: Glucose Monitoring Visit
This Cardi-OH document is helpful to inform or monitor treatment adjustments and lifestyle choices, helpful during illness, and for monitoring hypoglycemia.
A1.6: Remote Monitoring for Diabetes: Embracing Technology to Improve Patient Care
The Cardi-OH Webinar discusses how primary care teams can implement SMBG and CGM with patients.
A1.7: Find and Compare CGMs
A1.8: American Association of Clinical Endocrinology Slides on Interpreting CGM
Describes how to interpret CGM.
A1.9: Interpretation of Continuous Glucose Monitoring in Primary Care: A Case-Based Approach
Cardi-OH Webinar slides review basic elements of an ambulatory glucose profile and identify common patterns. Troubleshooting scenarios are explored in a series of cases.
A1.10: ADCES Diabetes Coding Table of CGM Education and Interpretation
Lists billing codes to maximize return on investment in diabetes care and education that can be used for CGM education and interpretation.
A2: Medication Management and Adherence
Dashboard Data Measures: % of adults with diabetes and A1C > 9 on insulin; % of adults with diabetes and A1C > 9 on newer medications; % of adults with diabetes and A1C > 9 on a specific number of medications; and, for medication adherence, the mean medication possession ratio for patients with diabetes.
Medication intensification (starting or increasing a diabetes medication), medication adherence (or medication taking), and lifestyle change are Key Drivers of improved A1C control.19 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 sugar control. In addition, the American Diabetes Association 2024 Standards of Care recommends to consider metabolic surgery as a weight and glycemic management approach in people with diabetes with BMI ≥ 30.0 kg/m2 (or ≥ 27.5 kg/m2 in Asian American individuals) who are otherwise good surgical candidates.19 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.
A2.1: Adapted ADA Treatment Algorithm
A2.2: Simplified Prescription of Diabetes Technology and Medications
Cardi-OH Capsule highlighting treatment options on the Medicaid formulary.
A2.3: Outpatient Diabetes Management for Primary Care Providers: Medications Intensification and Algorithm
This Cardi-OH document evidence-based strategies for pharmacologic management of type 2 diabetes in outpatient settings while focusing on newer therapies and treatment intensification strategies.
A2.4: Cardi-OH Radio Podcast 21 - Talking With Your Patients: Insulin Initiation and Administration
The podcast discusses common barriers to insulin initiation and administration in the primary care office. The interview includes a patient education example and tips for ordering diabetes and insulin supplies.
A2.5: Minimizing Hypoglycemia Risk to Improve Cardiovascular Health
This Cardi-OH document characterizes the complex relationship between tight glycemic control, severe hypoglycemia, and cardiovascular events. It describes an individualized approach to glycemic control for patients with type 2 diabetes to reduce hypoglycemia risk and maximize cardiovascular health.
A2.6: Cardi-OH Radio Podcast 13 - The Lowdown on Low Blood Sugar: Hypoglycemia in the Patient with Diabetes
Getting people started on insulin - discusses hypoglycemia in the patient with diabetes, how to address the frequency and consequences of this adverse condition, identify key risk factors, and describe practical management strategies for prevention and treatment when it does occur.
A2.7: Cardi-OH Radio Podcast 5 - Medication Adherence: a Driver of Patient Outcomes
The podcast discusses medication adherence in primary care with a special focus on care delivered via telemedicine, identifies strategies to improve medication adherence and discusses the important role of pharmacists in the care of patients with chronic conditions.
A2.8: Million Hearts Medication Adherence
Numerous strategies can improve adherence, including educating patients, simplifying treatment, and coordinating patient care across the health care team
A2.9: ADA Therapeutic Inertia Toolkit
These resources help you spot areas where inertia might occur in your practice. It also guides you in creating effective care plans with your patients and in removing barriers to treatment.