CMSHealthDisparitie

In the “Prevention: Disparities” sub-national task, QIOs are working to support diabetes self-management education (DSME) for underserved Medicare beneficiaries who have diabetes.  Also called “Every Diabetic Counts (EDC),” the program focuses on increasing beneficiary knowledge of diabetes management and improving access to and utilization of important diabetes management tests (i.e., glycosylated hemoglobin, lipids, eye exams, and blood pressure) through community and partnership outreach. The Centers for Medicare & Medicaid Services (CMS) has worked to establish a uniform and core approach which will enable coordinated evaluation at the national level.  This approach will entail:

HCD International contracts with CMS to serve as the Health Disparities Quality Improvement Organization Support Center (HDQIOSC) to focus on the EDC project.  The HDQIOSC will provide technical assistance, quality data reporting, communications outreach and marketing, materials development and strategic interventions for recruitment and retention.

EDC QIOs are evaluated on the number of physician practices recruited, improvement in utilization of glycosylated hemoglobin (HbA1C) testing, eye exams, lipid testing, and blood pressure testing, as well as, on the improvement in test results.  At a national level, the QIOs are expected to recruit nearly 600 physicians for and track nearly 11,000 beneficiaries through the Diabetes Self-Management Training Program.

QIOs in the following States/Jurisdictions have been awarded contracts to support this effort:  District of Columbia (D.C.), Georgia, Louisiana, Maryland, New York, Tennessee and the U.S. Virgin Islands.

District of Columbia (D.C.):

The Delmarva Foundation’s approach is based on the Chronic Care Model which has proven to significantly improve diabetes outcomes in the underserved population in urban settings with comparable populations to D.C.  Delmarva is using care teams to coordinate and deliver care. Community health workers (CHW) are utilized to lower barriers of care in assisting patients to become active participants in their own care.  Delmarva’s goals are to recruit 125 providers and train 1,500 patients.

Georgia:

The Georgia Medical Care Foundation (GMCF) is offering DSME classes at no cost, to eligible African-American and Hispanic Medicare beneficiaries in several northern and central Georgia counties.  GMCF is training nurses, certified diabetes educators (CDEs), dietitians, and Community Health Workers (CHWs) to provide DSME training.  The project goals are to recruit 200 providers and to train 2,627 patients.

Louisiana:

The Louisiana Health Care Review (LHCR) is working to help senior-age African-Americans with diabetes stay healthy by improving provider and patient diabetes disease management.  Forty physician offices and 2,400 patients from selected parishes are involved in this project. 

Maryland:

The Delmarva Foundation for Medical Care’s (DFMC) approach is based on the Chronic Care Model, which has proven to significantly improve diabetes outcomes in the underserved population in urban settings with comparable populations to D.C.  DFMC is using care teams to coordinate and deliver care, and CHWs to lower barriers of care in assisting patients to become active participants in their own care.  DFMC’s goals are to recruit 150 providers and train 1,750 patients.

New York:

IPRO is working with 64 physician offices, community health centers and hospital-based clinics to provide DSME to 2,500 Medicare beneficiaries in selected boroughs in the state.  IPRO’s project focuses on outreach, participant support, and partnership.  IPRO’s network of partners includes hundreds of senior centers, churches and community organizations, as well as, health coalitions, State and local government, and professional organizations.

Tennessee:

Healthcare Management Solutions (HMS) is working with 40 physician practices to provide DSME to 1,500 Medicare beneficiaries. This project is slightly different from the other EDC projects in that it is designed to decrease the incidence of morbid diabetes outcomes, as well as, well as, the incidence of progression to chronic kidney disease.  In addition to extensive partnerships, the project uses health provider facilitators (called “Community Champions”) to facilitate access to primary care practices and community facilitators to assist in defining the community resources that are available and to provide insight into how clinical practice can be effectively linked to public health interventions for the benefit of the patients.   The Tennessee project is a unique project co-sponsored by CMS and the National Institutes of Health.

U.S. Virgin Islands:

Virgin Islands Medical Institute (VIMI) is working with three providers to train 200 African-American and Hispanic Medicare beneficiaries in diabetes self-management.  VIMI is partnering with physicians and clinics territory-wide to encourage their patients to attend the classes.  VIMI faces a unique set of challenges in implementing programs like EDC because of the lower standard of living, transportation challenges and other logistic problems found in an island setting.

Prevention:  9th SoW “Focused Disparities” Measure Level (3 measures)

Health Disparities Quality Improvement Organization Support Center (QIOSC)

HCD International serves as the national QIOSC for CMS.

Evaluation

For the diabetes sub-national component, QIOs will be evaluated based on improvements within their states/jurisdictions in rates of hemoglobin (HbA1C) control, LDL cholesterol levels, blood pressure control, and eye exams.