Increasing the Rates of Patients with Controlled Diabetes in the Rio Grande Valley, TX
Through diabetes programs at primary care practices, a diabetes education center, and patient outreach, the Rio Grande Valley Accountable Care Organization Health Providers, LLC (RGV ACO) has been working to increase the number of patients who are successfully controlling their diabetes. RGV ACO was established in 2012 as part of the Medicare Shared Savings Program. This program aims to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-for-Service beneficiaries and reduce unnecessary costs. The mission of RGV ACO is to “[improve] the quality of life and health [of patients] through the effective practice of patient-centered preventive care.”
In 2012, the percentage of RGV ACO participants with diabetes was 42.8%. Since 2012, RGV ACO has taken actions to address this issue. RGV ACO’s diabetes initiatives aim to help patients understand their disease, encourage lifestyle changes, employ disease management techniques, and connect patients to additional support when needed. All of the primary care practices in RGV ACO offer a diabetes program to their patients, although the approach and intensity of such programs varies among practices. Some offices run an “uncontrolled diabetes mellitus clinic” once a week and have a nutritionist technician available to see patients before or after office visits. Some offices also employ staff to make phone calls to patients with uncontrolled diabetes as often as every other day, which allows staff to make adjustments to medications and increases patient engagement.
RGV ACO has also established the Diabetes Education Center, which is certified by the American Diabetes Association, to provide additional support to patients and physician practices. At the center, patients work with certified diabetes educators who help them better understand their disease and nutritionists who provide additional support. The center also provides training for medical assistants who work as care coordinators for diabetes patients, which helps ensure standardized application of best practices in diabetes management at all of the physician practices that are part of RGV ACO.
RGV ACO providers conduct outreach to patients with an HbA1c greater than 8 and newly diagnosed patients to encourage their participation in one of RGV ACO’s diabetes programs. Across RGV ACO, providers are reaching approximately 80% of the target patient population, and of the patients targeted, approximately 70% participate in at least 1 of the diabetes programs. Through their diabetes initiatives, RGV ACO has seen an increase in the number of patients who were successfully controlling their diabetes, from 23.29% in 2012 to 49.17% in 2014.1 This program is working to empower individuals with diabetes and help them take control of their condition.
1 Successful control of diabetes as measured by the Composite Measure of ACO measures 22–26, which is comprised of the following measures: Hemoglobin A1c Control <8%; Low Density Lipoprotein <100mg/dL; Blood pressure <140/90; Tobacco non-use; and Aspirin Use.
Diabetes Education Center
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