B. Access to High-Quality Coordinated Care

Dashboard Data Measure: % of people with diabetes and A1C ≥ 9% with a scheduled follow-up visit either in person or telehealth within 30 days.

Timely follow-up is important for patients with diabetes whose A1C is above goal. We promote at least monthly follow-up visits in any evidence-based approach (e.g., back with provider, clinical pharmacist, diabetes self-management education, nurse-led visits, and dietitians) either in person or using telehealth until the blood glucose is at goal. We base this approach on studies showing benefit in greater A1C improvements when patients have shorter intervals between visits^13-15 as well as our prior regional and statewide efforts that used this as one aspect of a QI project to improve glycemic control.¹⁷ When establishing processes for timely follow-up in team-based care, it is important to pay attention to continuity of care with the key team members (i.e., not having a different clinical pharmacist or nurse or primary care provider at each visit). Continuity of care within teams and providers has been associated with improved patient experience and outcomes.^18-20

Below are resources to assist primary care teams in implementing a process to ensure every patient receives an opportunity for timely follow-up.

Pre-visit planning includes scheduling individuals for follow-up at the end of their current visit, gathering information about the upcoming appointment (including individual concerns), obtaining labs prior to the visit, and spending a few minutes to huddle or hand off people with diabetes. A huddle of the health care team can be used at the start of the day, for instance, to identify individuals’ diabetes needs and to assign responsibility for task completion to individual team members. Beyond team huddles, practices can leverage EHR functionality, including pre-defined parameters that flag care gaps before the clinic day begins, enabling staff to proactively address patient needs during visits. Pre-visit planning fosters several activities known to improve A1C levels, including scheduling appointments to enhance timely follow-up for those with elevated blood glucose levels and action based on recent labs such as referral to diabetes self-management education and/or medication adjustments if the blood glucose level is elevated.

Example Data Measure (Not on Dashboard): % adults with diabetes with A1C ≥ 9% with outreach attempt.

Outreach through text messaging, a patient portal, phone calls, or letters is an effective method for encouraging patients with elevated A1C with no followup appointment to schedule a follow-up visit. Uptake on outreach varies, but ranges between 10%-28% in clinics serving populations with less resources.^21-23 Often these outreach attempts are done two times a year using an electronic health record-based registry of patients with diabetes and elevated A1C with no scheduled follow-up within one month. However, outreach approaches have also been used in a more ongoing fashion by practices, such as weekly, using lists of patients seen the prior week with elevated A1C and no scheduled follow-up. Some practices have also used tailored outreach to engage specific subgroups to eliminate disparities, such as having a community health worker (CHW) call and engage patients in care. Following, we provide two high level process maps. The first process map shows a standard outreach approach that a clinic might use to re-engage patients in care. The second process map demonstrates a real-time outreach approach for patients who no show the day of their appointment. Outreach messaging you might use in your practice is also provided.