increasing physician screening, testing, and referral of ... · • type 2 diabetes risk...

Increasing Physician Screening, Testing, and Referral of Patients with Prediabetes to the National DPP Lifestyle

Change Program - A CASE STUDY ON CLINICAL

IMPLEMENTATION

Theviewsexpressedinthispresentationaretheauthors’anddonotreflecttheofficialpolicyorpositionoftheCentersforDiseaseControlandPreventionortheU.S.government.

Table of Contents

Executive Summary 6

The National Diabetes DPP Lifestyle Change Program 8

The American College of Preventive Medicine Demonstration Projects 11

Case Study 1: Federally Qualified Health Center: Northeast Missouri Health Council 15

Pre-Demonstration Project Approach 15

Demonstration Project 16

Success, Challenges, and Lessons Learned 20

Scalability and Next Steps 20

Case Study 2: Independent Practice Association: Accent on Health 21



Successes, Challenges, and Lessons Learned 24

Scalability and Next Steps 25

Case Study 3: Independent Practice Association: Griffin Faculty Physicians 26



Summary of Challenges 33

Summary of Successes 34

Challenges 37

Conclusion 38

Resources 40

Acknowledgements

AbouttheCentersforDiseaseControlandPrevention(CDC),DivisionofDiabetesTranslationTheCDCDivisionofDiabetesTranslation(DDT)workstoreducethepreventableburdenofdiabetesthroughpublichealthleadership,partnership,research,programs,andpoliciesthattranslatescienceintopractice.Strategicgoalsfocuson:

• Preventingtype2diabetes;• Preventingcomplications,disabilities,andburdenassociatedwithdiabetes;and• Eliminatingdiabetes-relatedhealthdisparities.

AbouttheAmericanCollegeofPreventiveMedicineTheAmericanCollegeofPreventiveMedicine(ACPM)isaprofessionalmedicalsocietyofmorethan2,700preventivemedicineandpublichealthphysicianswhomanage,research,andinfluencepopulationhealth.Preventivemedicinephysiciansareemployedinawiderangeofsectorsandsettings,andACPMFellowsaresoughtafterleadersinlocal,national,andinternationalhealthsectors.Tothesespecialists,ACPMprovidesadynamicforumfortheexchangeofknowledgeandoffershigh-qualityeducationalprogramsaswellasprofessionaldevelopmentresourcesandnetworkingopportunities.

KeyProjectContributors:

• LianaLianov,MD,MPH,FACPM,FACLM,HealthTypeLLC• HeatherTindallReadhead,MD,MPH,UniversityofCaliforniaBerkeley• ShannonM.Haworth,MA,AmericanCollegeofPreventiveMedicine• DaniellePere,MPM,AmericanCollegeofPreventiveMedicine• MarissaHudson,BS,AmericanCollegeofPreventiveMedicine

ProjectFunding:TheAmericanCollegeofPreventiveMedicineissupportedbyafive-yearcooperativeagreement(#6NU38OT000130-05-01)fromtheCDCOfficeofState,Tribal,Local,andTerritorialSupport(OSTLTS).ForMoreInformationontheProject:

PleasecontactDaniellePere,VicePresidentofPrograms&Education,ACPM,[email protected]

AmericanCollegeofPreventiveMedicine455MassachusettsAvenueNW,Suite200

Washington,[email protected]

Increasing Physician Screening, Testing, and Referral of Patients with Prediabetes to the National DPP Lifestyle Change Program 5

Executive Summary

PrediabetesandType2diabetesareserioushealthconcernsthataffectalargeportionoftheUnitedStatespopulation.TheAmericanCollegeofPreventiveMedicine(ACPM)in2016undertookatwo-yearprojecttoraiseawarenessoftheseconditionsanddevelopprotocolsforscreening,testing,andreferringpatientswithprediabetestoCDC-recognizedorganizationsofferingtheNationalDiabetesPreventionProgram(NationalDPP)lifestylechangeprogram.

Inthetwo-yearproject,ACPMoversawninedemonstrationprojectstohelpclinicsandhealthcareorganizationsinterestedindevelopingandimplementingprediabetesscreening,testing,andreferralmodels.

Thiscasestudyreviewstheapproaches,barriers,scalabilityplans,andrelatedlessonslearnedofthreeofthesehealthcareorganizations:

• NortheastMissouriHealthCenter–Kirksville,Missouri(FQHC)• AccentonHealth–Washington,DC(IPA)• GriffinFacultyAssociates–Derby,Connecticut(IPA)

The focusof theprojectwas to increasephysicians’/health careprofessionals’ awarenessofprediabetes as aserious health condition; develop and implement protocols for screening, testing, and referring patientswithprediabetestoaCDC-recognizedorganizationofferingtheNationalDPPlifestylechangeprogram;andincreasethe number of physicians/health care professionals taking action to screen, test, and refer patients withprediabetestoCDC-recognizedorganizations(organizationswithpending,preliminary,orfullrecognition).

Promisingpracticesidentifiedinthecasestudyspeaktothesimilaritiesinhealthcaredeliverydespitevariationsingeographiclocation,patientpopulations,orinsurancecoverage.

Thiscasestudyisaresourcethatwillhelpclinicsandhealthcareorganizationsinterestedinimprovingordevelopingandimplementingprediabetesscreening,testing,andreferralmodels.

Keyareasforlessonslearnedwereorganizedby:• ProviderConcerns• Delays• Communication/Awareness• Technology• Processes/Workflow

Keytakeaways:

• Type2diabetesriskassessmentsshouldbeincorporatedintostandard,easilyrepeatableworkflowproceduresforprovidersandstaff.Oncethatworkflowisestablishedandimplemented,itshouldbecomeroutine,muchliketakingapatient’sweightorbloodpressure.

• Addinganothersteptoanestablishedpracticeworkflowcantakephysicians/providerstimetorevisetheworkflow.

• Communicationandeducationforpatientsandprovidersalikeiscriticaltosuccess.Systems,processes,andtechnologycanbeputtocoordinatedusetoovercomesomeofthesechallenges.Educationcancomeintheformofautomatedtechnology,emailand/orotherdigitalplatforms,andtraining.

• Using technology to conduct quality assurance reviews of data, and minimizing delays by using bulkmessaging functions within an EHR, are additional ways to improve the process for providers andpatients.

Thiscasestudyshowsclearbenefitsofacoordinatedapproachtodevelopingandimplementingprediabetesscreening,testing,andreferralmodels.Identifyingkeypointsofcontactforpatientsandprovidershelpsfacilitatebuy-inacrossthefullspectrumofpatientcare.


IncreasingPhysicianScreening,TestingandReferralofPatientswithPrediabetestotheNationalDPPLifestyleChangeProgram 8

1NationalInstitutesofHealth.DiabetesPreventionProgramFactSheet.Retrievedfrom:https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp2Long-termeffectsoflifestyleinterventionormetforminondiabetesdevelopmentandmicrovascularcomplicationsover15-yearfollow-up:theDiabetesPreventionProgramOutcomesStudy.Retrievedfrom:https://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00291-0/fulltext

The National Diabetes Prevention Program: TheCDC-ledNationalDiabetesPreventionProgram(NationalDPP)isapartnershipofpublicandprivateorganizationsworkingtogethertobuildanationwidedeliverysystemforalifestylechangeprogramproventopreventordelayonsetoftype2diabetesinadultswithprediabetes.TheNationalDPPprovidesaframeworkfortype2diabetespreventioneffortsintheU.S.foundedonfourkeypillars:1)atrainedworkforceoflifestylecoaches;2)nationalqualitystandardssupportedbytheCDCDiabetesPreventionRecognitionProgram;3)anetworkofprogramdeliveryorganizationssustainedthroughcoverage;and4)participantuptakeandreferral.1ThesepillarslinkcloselytotheCDC’sstrategicgoalsfortheNationalDPP:increasethesupplyofqualityprograms;increasedemandfortheprogramamongpeopleatrisk;increasereferralsfromhealthcareproviders;andincreasecoverageamongpublicandprivatepayers.1

AkeycomponentoftheNationalDPPisastructured,evidence-based,year-longlifestylechangeprogramtopreventordelayonsetoftype2diabetesinadultswithprediabetesoratriskofdevelopingtype2diabetes.1TheNationalDPPlifestylechangeprogramisfoundedonthescienceoftheDiabetesPreventionProgramresearchstudy,andsubsequenttranslationstudies,whichshowedthatmakingrealisticbehaviorchangeshelpedpeoplewithprediabeteslose5%to7%oftheirbodyweightandreducetheirriskofdevelopingtype2diabetesby58%(71%forpeopleover60yearsold).1ThegroundbreakingDPPstudyenrolled3,324overweightparticipantswithelevatedfastingandpost-loadplasmaglucoseconcentrations.Participantswererandomlyassignedtothreegroupsinthestudy:lifestyle,metformin,andplacebo.Theprimaryoutcomemeasurewasdevelopmentoftype2diabetes,diagnosedonthebasisofanannualoralglucose-tolerancetestorasemiannualfastingplasmaglucosetest.1Resultsshowedthatbothlifestylechangeandtreatmentwithmetforminreducedtheincidenceoftype2diabetesinpersonsathighriskcomparedwithaplacebo,butthelifestyleinterventionprovedmoreeffectivethanmetformininpreventingtheonsetoftype2diabetes(Diagram1).1TheDPP’sresultsalsoindicatedthatmillionsofhigh-riskadultscanpreventordelayonsetoftype2diabetesbylosingweightthroughastructuredlifestyleinterventionemphasizingregularphysicalactivityandadietlowinfatandcalories.After15yearsofstudy,participantsinthelifestyleinterventiongroupcontinuetohavea27%reducedriskofdevelopingtype2diabetescomparedtoan18%reducedriskinthemetformingroup.2

The National Diabetes Prevention Program:

Theprogramisgroup-based,facilitatedbyatrainedlifestylecoach,andusesaCDC-approvedcurriculum.Thecurriculumsupportsregularinteractionbetweenthelifestylecoachandparticipants;buildspeersupport;andfocusesonbehaviormodificationthroughhealthyeating,increasingphysicalactivity,andmanagingstress.Theprogrammaybedeliveredin-person,online,viadistancelearning,orthroughacombinationofthesedeliverymodesandconsistsof:

• Aninitialsix-monthphaseofferingaminimumof16sessionsover16to24weeks.• Asecondsix-monthphaseofferingaminimumofonesessionamonth(atleastsixsessions).• Facilitationbyatrainedlifestylecoach.• ACDC-approvedcurriculum.• Regularopportunitiesfordirectinteractionbetweenthelifestylecoachandparticipants.• Afocusonbehaviormodificationthroughhealthyeating,increasingphysicalactivity,managing

stress,andpeersupport.


CDC’sDiabetesPreventionRecognitionProgram(DPRP)isthequalityassurancearmoftheNationalDPP.ThroughtheDPRP,CDCawardsrecognitiontoprogramdeliveryorganizationsthatmeetnationalstandardsandachievetheoutcomesproventopreventordelayonsetoftype2diabetes.

AsofJuly2018,thereweremorethan1,700in-personandvirtualorganizationsintheDPRPregistrythathadenrolledmorethan230,000participants.CoveragefortheNationalDPPlifestylechangeprogramasahealthbenefitisexpanding.3AsofJuly2018,over3.4millionpublicemployeesanddependentsin19stateshadtheNationalDPPlifestylechangeprogramasacoveredbenefit,andmorethan100employersandinsurerswerecoveringtheprograminvariousmarkets.4

OnNovember2,2017,theCentersforMedicare&MedicaidServices(CMS)issuedthe2018PhysicianFeeSchedule(PFS)finalrule,whichfinalizedpoliciestoimplementtheMedicareDiabetesPreventionProgram(MDPP)expandedmodel,whichtookeffectonApril1,2018.4TheMDPPexpandedmodelallowsMedicarebeneficiarieswithprediabetestoaccesstheNationalDPPlifestylechangeprogramasacoveredservice.AnMDPPsupplierisanorganizationthatisenrolledinMedicareandcanbillforMDPPservicesprovidedtoeligiblebeneficiaries.5InordertoapplytobecomeanMDPPsupplier,anorganizationmusthavepreliminaryorfullrecognitionfromCDC’sDPRP.

3IncreasingCoveragefortheNationalDPPthroughPublicandPrivateEmployers,CommercialHealthPlans,andMedicaid.Retrievedfrom:https://www.cdc.gov/diabetes/programs/stateandlocal/resources/increasing-coverage.html4CentersforMedicare&MedicaidServices.FactSheet:FinalPoliciesfortheMedicareDiabetesPreventionProgramExpandedModelintheCalendarYear2018PhysicianFeeScheduleFinalRule.Retrievedfrom:https://innovation.cms.gov/Files/fact-sheet/mdpp-cy2018fr-fs.pdf5MedicareDiabetesPreventionProgram(MDPP):MDPPSupplierRoadMap.Retrievedfrom:https://innovation.cms.gov/Files/x/mdpp-orientation_roadmap.pdf


TostartMDPPservices,beneficiariesmusthave:• MedicarePartBcoveragethroughMedicareFee-for-ServiceoraMedicare

Advantage(MA)Plan.• Resultsfromoneofthreebloodtestsconductedwithinoneyearbeforethefirstcore

session:

--HemoglobinA1C:5.7--6.4%or--Fastingplasmaglucose:110--125mg/dLor--Oralglucosetolerancetestwithavalueof140--199mg/dl

• BodyMassIndex(BMI)ofatleast25,oratleast23ifself-identifiedasAsian• Nohistoryoftype1or2diabetes,withtheexceptionofgestationaldiabetes• NoEndStageRenalDisease(ESRD)• NotreceivedMDPPservicespreviously

Diagram 2. Requirements to Start MDPP Services

Source:https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/)andtheMDPPoverviewfactsheet(https://innovation.cms.gov/Files/x/MDPP_Overview_Fact_Sheet.pdf)

The American College of Preventive Medicine Demonstration Projects

Infall2016,TheAmericanCollegeofPreventiveMedicine(ACPM)wasfundedbytheCDCDivisionofDiabetesTranslationtoincreasescreening,testing,andreferralofpeoplewithprediabetestoorganizationsofferingtheNationalDPPlifestylechangeprogramandparticipatingintheCDCDiabetesPreventionRecognitionProgram(CDC-recognizedorganizations).

Fortwoyears,ACPMoversawninedemonstrationprojectsforhealthcareorganizations/practiceswiththegoalsof:

1. Increasingphysicians’/healthcareprofessionals’awarenessofprediabetesasaserioushealthcondition.2. Developingandimplementingprotocolsforscreening,testing,andreferringpatientswithprediabetestoa

CDC-recognizedorganization,eitherthroughtheEHRorbyusinganothernon-electronicapproach.3. Increasingthenumberofphysicians/healthcareprofessionalstakingactiontoscreen,test,andrefer

patientswithprediabetestoCDC-recognizedorganizations(organizationswithpending,preliminary,orfullrecognition).

CriteriaforScreeningandTesting:

Source: National Diabetes Prevention Program, CDC

12

• Beatleast18yearsoldand• Beoverweight(bodymassindex≥25;≥23ifAsian)and• Havenopreviousdiagnosisoftype1ortype2diabetesand• Haveabloodtestresultintheprediabetesrangewithinthepastyear:

--HemoglobinA1C:5.7--6.4%or--Fastingplasmaglucose:100--125mg/dLor--Two-hourplasmaglucose(aftera75gmglucoseload):140--199mg/dLor

• Bepreviouslydiagnosedwithgestationaldiabetes

Prediabetescanbediagnosedviaafastingplasmaglucose,anoralglucosetolerancetest,oranA1Ctest.Blood-basedtestingisthemostaccuratewaytodetermineifapatienthasprediabetes.

ViaacompetitiveRequestforProposal(RFP)process,ACPMelectedtofundorganizationsthatrepresentedavarietyofclinicalpracticesettings,aseachsettingwaslikelytobeuniqueinthetypesofstrategiesandresourcesneededtoestablishascalablereferralmodel.Providergroupswereselectedfromeachofthethreecategorieslistedbelow,andeachprovidergroupreceived$15,000todevelopscalablemodelsforscreening,testing,andreferral.AwardrecipientsworkedwithACPMtodocumenttheirexperiencesandlessonslearnedascasestudiestoinformandteachothers.Thegranteeswereselectedfromthefollowinghealthcaresettings:CommunityHealthCentersorFederallyQualifiedHealthCenters(FQHC);FQHCLook-Alikes;RuralHealthClinics;FreeandCharitableClinics:

• FQHC:AnyproviderworkinginaFederallyQualifiedHealthCenter,asdesignatedbytheHealthResourcesandServicesAdministration(HRSA),waseligibletoapplyforthegrant.Thisincludedhealthcentersthatservehomelesspatients,farmworkerpatients,publichousingpatients,andveteranpatients.

• FQHCLook-Alike:AnyproviderworkinginaFQHCLook-Alike,asdesignatedbyHRSA,waseligibletoapplyforthegrant.

• RuralHealthClinic:AnyproviderworkinginaRuralHealthClinic(RHC),asdesignatedHRSA,waseligibletoapplyforthegrant.

• FreeandCharitableClinics:ThesearehealthclinicslocatedacrossthecountrythatdonotreceiveanyfederalfundsthataregiventoFQHCsandRHCs.Theyalsoreceivelittletonostatefunds.Anyproviderwhovolunteeredasignificantportionofhis/hertime(atleasttwodaysaweek)atafreeorcharitableclinicwaseligibletoapply.

• IndependentPhysicianAssociations(IPA)andMedicalGroups:AnyproviderinanIPApursuingopportunitiessuchascontractswithemployers,accountablecareorganizations(ACO),ormanagedcareorganizations(MCO)wasencouragedtoapply.Physiciansinmedicalgroupsalsoengagedinpatient-centeredmedicalhomes(PCMH)wereencouragedtoapply.

• IntegratedDeliverySystem(IDS):Anyproviderworkinginanintegrateddeliverysystem(IDS)thatis

verticallyandhorizontallyalignedtoprovideacontinuumofcaretoaspecificgeographicareainneedwaseligibletoapply.AnyproviderwithinanIDSthatfunctionsasanACOwasalsoeligibletoapply.


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Duringtheinitialyearofthedemonstrationproject,ACPMselectedthreeorganizations*:• EmoryHealthcareSystem–Atlanta,GA(IDS)• WheatRidgeInternalMedicine–WheatRidge,CO(IPA)• AltaMedHealthServices–LosAngeles,CA(FQHC)

*Formoreinformationontheseorganizations,seeACPM’sYear1NationalDPPdemonstrationprojectcasestudy“IncreasingPhysicianScreening,Testing,andReferralofPatientswithPrediabetestotheNationalDiabetesPreventionProgramLifestyleChangeProgram.”

Duringthesecondyearofthedemonstrationproject,ACPMselectedsixorganizations:• NortheastMissouriHealthCenter–Kirksville,Missouri(FQHC)• ChristopherRuralHealthCorporation–Christopher,Illinois(FQHC)• MaineHealth–Portland,Maine(IDS)• SouthNassauCommunityHospital–Oceanside,NewYork(IDS)• GriffinFacultyAssociates–Derby,Connecticut(IPA)• AccentonHealth–Washington,DC(IPA)

Thiscasestudyreviewstheapproaches,barriers,andscalabilityplansofthreeofthesehealthcareorganizations:

• NortheastMissouriHealthCenter–Kirksville,Missouri(FQHC)• AccentonHealth–Washington,DC(IPA)• GriffinFacultyAssociates–Derby,Connecticut(IPA)

CASE STUDY 1

Federally Qualif ied Health Center: Northeast Missouri Health Council

NortheastMissouriHealthCouncil(NMHC)isaFederallyQualifiedHealthCenterthathasbeenprovidingservicessince1968.In2016,NMHCprovidedservicesto19,499residentsthroughfourfamilyhealthclinics,anOB/GYNclinic,apediatricclinic,aVeteransAdministrationcommunity-basedoutpatientclinic,andthreedentalclinics.NMHCprovidesaslidingfeescalefortheuninsured/underinsuredandacceptstraditionalMedicaid,MedicaidManagedCare,Medicare,andprivateinsurance.NMHC’sserviceareaincludes11countiesinnortheastMissouri,allofwhichareHealthProfessionalShortageAreas.AccordingtotheU.S.Census,over40%ofthepopulationintheserviceareaislivinginhouseholdswithincomesbelowthefederalpovertylevel.Inaddition,thepercentageofadultsintheserviceareawhoareobese(BodyMassIndexgreaterthan30)is32.4%,comparedto30.3%inMissouriand27.1%intheUnitedStates.Residentsinthe11-countyareawerediagnosedwithdiabetesatarateof11.6per100,000,alsoexceedingthenationalbenchmarkof8per100,000.6

Pre-Demonstration Project Approach

Priortothedemonstrationproject,NMHCappliedtotheCDCDiabetesPreventionRecognitionProgramandreceivedpendingrecognitionforitsNationalDPPlifestylechangeprogram.NMHCdevelopedstaffworkflowsforbothclinicvisitsandphonecallstosupportandeducatepatientswithprediabetesabouttype2diabetespreventionandthelifestylechangeprogram.

NMHCHealthInformationSystemsstaffcompletedretroactivescreeningusingtheEHRtoidentify631patientswhowereatriskofdevelopingtype2diabetesandeligiblefortheprogram.Basedonthisdata,NMHCthenextractedpatientswhowereseenbyprovidersattheNortheastFamilyHealthCliniclocatedinKirksville,Missouri,tocreateaprediabetesregistryspecificallyforthisclinic.

15

6NMHCDemonstrationProject2018MidtermReport.

Duringthedemonstrationproject,(NMHC)focusedon:

• UtilizingexistingNationalDPPmarketing,patientawareness,andscreeningandreferralresourcesfromtheCDCandorganizationssuchastheAmericanMedicalAssociation(PreventDiabetesSTATToolkit).

• Organizingandimplementingacommunication/marketingstrategytoincreaseawarenessoftheprogram,includingeducationandscreeningofpatientsandothercommunitymembersandeducationforprovidersandclinicstaff.

• Developingastandardmodelforidentificationofatargetpopulationviaretroactivescreeningoftheclinicpopulationeverysixmonths.

Eachoftheseapproachesisdescribedbelow.

Developing Awareness: Education and Screening of Patients and Community Members

NMHCutilizedavarietyofresourcestopromotetheavailabilityofscreeningandreferraltotheprogramincluding:

• Electronicbillboardwithaprediabetesawarenessmessage.

• Promotionoftheprogramatlocalfestivalsandothercommunityevents.The“CommunityRootsFestival”yieldedapproximately1,500paper-basedscreeningformscompletedbyNortheastMissouriresidentswhowerethenprovidedinformationontheNationalDPPlifestylechangeprogram.

• MeetingsheldattheclinicinpartnershipwiththeAdairCountyYMCAtoprovidebloodpressureandweightscreeningsforapproximately40-50peopleeachmonth.InformationsuchastheCDCPrediabetesRiskTestwasdistributedtoparticipants.

• Meetingsheldmonthlyattheclinicforpatientsandcommunitymemberswantingtolearnmoreabouttheprogram(SessionZeroInformationOverview).

• Postershunginclinicexamrooms(PromotingPrediabetesAwarenesstoyourPatients-providedbytheMissouriDepartmentofHealth).


Demonstrat ion Project

• Aone-pageflyerforthe65yearsofageandolderpopulationthatfocusedonthe71%type2diabetesriskreductionseeninthosewhocompletedtheoriginalDPPresearchtrial,andthecostsassociatedwithtype2diabetes(PrediabetesIsaBigDeal).

• Informationmailedtopatientstoassistwithself-referrals(CDCPrediabetesRiskTestandprogram/referralinformation).

• Paperscreeningincorporatedintotheworkflowattheclinictoassistwithreferrals(CDCPrediabetesRiskTestandprogram/referralinformation).

Developing Awareness: Education for Providers and Clinic Staff

NMHCusedthefollowingactivitiestoincreaseproviderandclinicstaffscreeningandprogramreferrals:

• TheNMHCDiabetesEducationQualityCoordinatorprovidedanoverviewoftheNationalDPPlifestylechangeprogram,outcomesoftheDPPresearchtrial,andprevalenceofprediabetesinMissouriandtheNMHCserviceareaatmonthlyNMHCproviderandstaffmeetingsandattheNortheastMissouriHealthCouncilBi-AnnualQualityImprovementmeeting.

• Duringmonthlyproviderandstaffmeetings,NMHCstaff(theDiabetesEducationQualityCoordinatorandtheReferralCoordinator)reviewedinstructionsforuseofthepaper-basedriskassessment,laboratoryvaluesforthediagnosisofprediabetes,updatesonthenumberofprogramreferralsandenrollees,andaggregatedataonparticipantoutcomes.

• NMHCproviderstookpartinmonthlyandthenbimonthlymeetingstoassistindevelopingtheworkflowforidentifyingandreferringpatients.

• NMHCstaff(theDiabetesEducationQualityCoordinatorandtheReferralCoordinator)providedfeedbacktoprovidersontheirindividualpatientsviatheEHRregardingreferrals,enrollment,andprogressinthelifestylechangeprogram.

Patient Identification

NMHCusedthePreventDiabetesSTATToolkitalgorithmtoretroactivelyscreentheirpatientpopulationforpatientseligibletoparticipateintheNationalDPPlifestylechangeprogram.HealthInformationSystemsstaffcompletedanEHRreportbasedonthefollowinginclusioncriteria:• Patientsage≥18years.• BMI≥25kg/m2;ANDpositiveresultforanyofthefollowing:HbA1c5.7–6.4%(LOINCcode1558-6)

orFPG100-125mg/dLorhistoryofgestationaldiabetes(ICD–10:Z86.32).• Exclusioncriteria:Currentdiagnosisofdiabetesorcurrentuseofinsulin.

NMHCmailedlettersandsupportinginformationtoallpatientswhoqualifiedbasedontheretroactivealgorithm.Duetothehighvolumeofreferrallettersbeingsent,theclinicdidnotcreatethelettersaspartoftheEHR.NMHCpersonalizedthelettersusingMicrosoftsoftwareandanExcelreport.Theletteraddressedthepatient’sriskofdevelopingtype2diabetesandtheprovider’srecommendationtoenrollintheNationalDPPlifestylechangeprogram.AcopyoftheCDCPrediabetesScreeningTestwasmailedwiththeletter.

NMHCsortedthereportofallqualifyingpatientsbyprovider,givingeachprovideralistofhis/herpatientswhoweredeterminedtobeatrisk.Subsequently,eachprovideridentifiedthosepatientsathighestriskofdevelopingtype2diabeteswhohadexhibitedreadinesstocommittotheprogram.Thesepatientsreceivedaphonecalltofollowupontheletterthathadbeenpreviouslymailed.Threeweeksaftermailingtheletter,iftheNMHCDiabetesPreventionProgramhadnotheardfromthepatient,thecoordinatingnurseworkingwiththeprogramfolloweduponetimeviaphone.ThenurseenteredtheprediabetesriskscreenerscoreintotheEHRandcreatedanEHRreferralifthepatientagreedtoparticipateintheprogram.

NMHCalsoidentifiedadditionalqualifyingcommunitymembersamongwomenwhowerealreadyparticipatinginotherhealtheducationprograms,includingtheShowMeHealthyWomanandtheWISEWOMANprogram.TheMissouriDepartmentofHealthandHumanServicesWISEWOMANprogramdirectorsagreedtoreimburseNMHCforthecostofWISEWOMANparticipantswhoqualifiedforparticipationintheNationalDPPlifestylechangeprogram.TheWISEWOMANprogramrequiresthattheparticipanthaveaBMIof25orgreaterandnothaveadiagnosisoftype1ortype2diabetes.AletterwassenttoallWISEWOMENparticipantswhoqualified,andnursingstaffalsoreferredWISEWOMENparticipantswithaBMI≥25totheprogram.

Altogether,1,076patientswereidentifiedforoutreachutilizingtheretrospectivequeryprocess(1,033)andfromtheWISEWOMANprogram(43).Informationwasmailedtoallidentifiedindividuals,includingtheCDCPrediabetesRiskTest,SessionZeroInformationOverview,and“PrediabetesisaBigDeal”handoutandprogram/referralinformation.The1,076patientswerebrokendownintolistsseparatedbyprimarycareprovider,dietitian,orOB/GYN.Providersthenselected93patientstoreceivefollowupbyphone.Asaresultofthemailerortelephonicfollowup,60patientscompletedtheCDCPrediabetesRiskTestandindicatedinterestinattendingaSessionZeroclassorreceivingadditionalinformationabouttheprogram(Table1).

Table 1. Patient Referrals and Enrollment

Referral Primary Category Number Referred

Number Enrolled

EHR Query: Patient contacted by phone to enroll

93

14

Point of care screening: Referred by provider; NMHC Diabetes Prevention Program employees completed final enrollment

52

20

Point of care screening: Patient received a warm hand-off to the NMHC Diabetes Prevention Program

21 of the 52 total electronic referrals

13/20 enrolled patients

Patients referred friends/family 5 TBD

Point of Care Model Referralswerealsoinitializedatthepointofcare.Theworkflowwasdevelopedbythesteeringcommitteethroughmonthlyorbimonthlyface-to-faceandteleconferencemeetings,andthroughemailfollow-up.ThepointofcareSTAT-ToolkitguidelinesandtheAmericanAssociationofClinicalEndocrinologist/AmericanCollegeofEndocrinologyComprehensiveType2DiabetesManagementAlgorithmwereusedasoriginalsourcestoeducatethesteeringcommitteeanddeveloptheworkflowforidentifying,screening,andreferringpatients.AworkflowwasdevelopedtodeterminewhichpatientswouldreceivetheCDCPrediabetesScreeningTestasseeninDiagram4.


Diagram 4. NMHC Screening and Referral Workflow

Successes, Challenges, and Lessons Learned ThedemonstrationprojectprovidedtheopportunitytoincreaseprediabetesawarenessacrossNMHClocationsbyprovidingtrainingforhealthcareprovidersandstaff.Thetrainingsprovidedopportunitiesfornursesandstafftoaskquestionsabouttheriskfactorscontributingtothedevelopmentoftype2diabetesandincreasedtheirabilitytoidentifyandreferpatientstotheNMHCDiabetesPreventionProgram.NMHChopedtoincreasethenumberofpatientswhoenrolledintheprogrambywarmhand-offreferralby50%.Ofthe52electronicreferralscompleted,21receivedawarmhandoff,therebymeetingthegoal.

Therewerechallengesencounteredwithprovidersduringtheprojectincluding:• PrimarycareprovidersinanFQHCsettingmonitorandaddressmanyitemsatthepatient

appointment.Thus,type2diabetesriskassessmentmaynotbethehighestconcernforthepatientorprovider.

• Ittakestheprovidertimetoaddanewscreeningorprograminformationtotheirworkflowinthealreadylimitedtimeofatypicalclinicappointment.Toaddressthisbarrier,workflowsweredevelopedtoallowotherstaffmemberstoassistinidentifyingpatientsforreferralandcommunicatingthisinformationtotheproviders.

Scalability and Next Steps Attheendoftheproject,thepilotedworkflowwillbeintegratedintothepracticeofallprimarycareproviders’atallfourfamilyhealthclinicsandtheOB/GYNspecialtyclinic.Bimonthlymeetingswillcontinuetoaddressthebarrierstoprediabetesscreening,testing,andreferralateachclinicsiteorwithindividualproviders.

If the NMHC Diabetes Prevention Program did not hear from the

patient within 3 weeks, the coordinating nurse followed up with the patient telephonically

The coordinating nurse entered the prediabetes risk screener

score into the EHR A referral was created in the EHR if the patient agreed to participate in the program

Health Information Systems staff completed an EHR report based

on the inclusion criteria

Providers identified patients at highest risk of developing type

2 diabetes who exhibited program readiness

Providers were given a list of their patients who were determined to be at risk

CDC Prediabetes Screening Test mailed with the letter

Letter created in the patient’s EHR to address type 2 diabetes risk

and recommend the National DPP lifestyle change program

CASE STUDY 2

Independent Practice Association: Accent on

Health

AccentonHealth(Accent)isasmallindependentpracticeinWashington,D.C.,comprisedofonephysician,onephysicianassistant,oneofficemanager,andthreemedicalassistants.Itspatientpopulationis94%AfricanAmericanadultsovertheageof20.Themajorityofpatientsarewomen(61%),andalargemajorityofpatientsareoverweightwithmorethanonehealthcondition(80%).Approximately35%ofpatientsseenattheclinichaveadiagnosisofdiabetes.Inaddition,itisestimatedthatanadditional50%haveprediabetes.

Pre-Demonstration Project Approach Prior to the demonstration project, Accent screened for prediabetes at annual wellness visits, withhemoglobinHbA1ctestingcompletedattheproviders’discretion.Providersalsocounseledpatientswithinthepracticesetting.Demonstration Project Accentdesigneditsdemonstrationprojecttofocuson:• Developingarobustin-clinicawarenessandpromotionmodel(forprovidersandpatients)by

customizingformsandmaterialstomeettheneedsoftheclinicandpatientpopulation.

• ConductingaretroactivereviewofEHRdataeverysixmonthstoidentifypatientswithprediabetesandreferthemtoaCDC-recognizedorganization,theFlexcarePharmacyDiabetesPreventionProgram,whichwasfullyfundedbythelocaldepartmentofhealth.

• Developingaworkflowforpatientcounselingandreferral.

• WorkingwithinexistingEHRsystems(FoxMeadowsEHR)tostreamlineareferralmodel.


Developing Awareness Accentimplementedthefollowingstepstoincreaseawarenessofprediabetesandtheimportanceofscreeningwithinthepracticesetting:• Patientposterswereplacedinthewaitingarea,examrooms,breakroom,andprovideroffices.

• TheADAType2DiabetesRiskTestwasplacedinthewaitingarea.

• Patientsandcaregiverswereencourageddailytoparticipateinthescreeningprocessaspartofthecheck-inandcheck-outprocess.

Effortstokeepprovidersengagedincludedmonthlylunchmeetingsto:• Evaluateprogramsuccessandchallenges.

• Discusslong-termsustainabilityoftheeffort.

• DiscussbenefitsoftheprogramrelevanttoimprovingpatienthealthoutcomesandmeetingMACRAgoals.

Patient Identification PatientsatriskwereidentifiedthrougharetrospectiveEHRqueryutilizingthealgorithminthePreventDiabetesSTATToolkitandEHRalertsinthesystemandatthepointofcare(seeDiagrams5and6).

Retrospective Query AllpatientsidentifiedthroughtheretrospectiveEHRqueryashavingprediabeteswerenotifiedviaregularmail.TheletterscontainedgeneralinformationabouttheNationalDPPlifestylechangeprogram,itsbenefits,andanumbertocontactforclassinformation.

Point of Care PatientsweregiventheADAType2DiabetesRiskTestwhentheycheckedinfortheirappointments.Thestaffatregistrationmadesurethateachpatientdidnothaveadiagnosisofdiabetesandwasnotpreviouslyidentifiedashavingprediabetes.Ifthepatient’sriskscorewas5orhigher,achartreviewwasperformedforfurtherevaluationfocusingonrecentBMIandHbA1cvalues.

EachpatientwithaBMIandHbA1cwithinthecriteriasetforthintheSTATtoolkitwasautomaticallyflaggedinthesystemasacandidateforadditionaleducationandreferraltotheNationalDPPlifestylechangeprogram.Theprovidersreviewedthisinformationbeforegoingintotheexamrooms,discussedthebenefitsoftheprogramwiththepatient,andsignedareferralformforthepatienttoparticipateintheprogram(Table2).


Table 2. Accent Patient Referrals and Enrollment

Referral Primary Category Number Referred

Number Enrolled

Point of care: Patient was provided information to self-enroll (EHR Retrospective Query)

89

n/a

Point of care: Patient enrolled by provider/clinic staff

39

38

Patient letter (total)

128

Other n/a

Diagram 5. Accent Retrospective EHR Review

EHR Review

Contact Patients

Fol low Up

Diagram 6. Accent Point of Care Workflow

Successes, Challenges, and Lessons Learned ThrougharetrospectivereviewofEHRdataandregularofficevisits,806patientelectronicrecordswerereviewed,and128patientswerediagnosedwithprediabetes.Ofthosediagnosedwithprediabetes,38enrolledintheFlexcarePharmacyDiabetesPreventionProgramwhichwasfullyfundedbythelocaldepartmentofhealth.TheSTATtoolkitwaseffectiveinscreeningforprediabetesinaprimarycaresetting,andtherewaslittleornoeffectondailyofficeworkflowduringtheimplementationoftheproject.

Therewerechallengesduringtheimplementationofthedemonstrationprojectthatpotentiallylimitedthereferralandenrollmentprocess.TheEHRsoftwareprovideratthetimeofthecasestudywasFoxMeadows.Thesoftwareproviderwasnotfamiliarwithprediabetesscreening,andthesoftwarewasnotdesignedtoincorporateprediabetesscreeningintheEHR.Thus,therewasnoeasyaccesstotheinformationbyprovidersandotherstaff.TherewasalsonodedicatedsectionintheEHRtotrackscreeninganddocumentfollowupefforts.Therewerealsochallengeswithreimbursementforbloodglucosetesting.ThesuggestedCPTcodes(i.e.CPTcode:99401)werenotveryhelpfulinbillingforprediabetestesting/abnormalbloodglucose,andonlytwoclaimswerereimbursedbyinsurancecompaniesusingthecodesprovided.


Provide patient with

CDC-recognized organization’s contact

information

Follow up with patient and CDC-recognized

organization

Check Out See Provider

Discuss prediabetes results

Discuss benefits of National DPP lifestyle change program

Sign referral form

Provide patient with health literature

Sign In

Prediabetes questionnaire

Check insurance coverage

BMI

Check lab for HbA1c

Flag System

LessonsLearned:• Establisharelationshipwiththeseorganizationsearlyonandobtaininformationontheirclass

schedules.• Anewsoftwareprogramandamoreexperiencedteamhandlingallbillingquestionsandconcerns

arecrucialforsuccess.• Localdepartmentsofhealthcanassistinpromotingtheprogramifinvolvedearlyintheprocess.• Peerleadersanddiabeteseducatorscanalsohelpinpromotingtheprogram.• ItisimportanttoverifythatthereareCDC-recognizedorganizationsinthecommunity,andthattheseprogramsare

abletomeettheneedsofpatientsreferredwithinareasonabletimeframe.• Thepracticemustcontinuetomakethisprogramaprioritytoensureitssuccess.

Scalability and Next Steps Accentisconsideringthefollowingnextsteps:• ChangingtonewEHRsoftwarewithbettercapabilitiestohandlepreventiveefforts.Accent’sexisting

systemwasnotdesignedtohandlesuchaninitiativeinaneffectivemanner.Upgradesrequiredwerecostprohibitive.

• Revisitingreimbursementconcernsforbloodglucosetesting.• AssigningadedicatedstaffmembertofollowupwithenrolledpatientsandwiththeCDC-recognized

organizationonaquarterlybasis.• Stayinginvolvedwiththelocaldepartmentofhealthtotakeadvantageofanyassistanceoffered.• LearningmoreabouttheMedicareDiabetesPreventionProgram.

25

CASE STUDY 3

Independent Practice Association: Griffin Faculty Physicians

GriffinFacultyPhysicians(GFP)hassevenprimarycareofficeswithatotalpatientpanelof20,978.AllofficesarerecognizedasPatientCenteredMedicalHomes.Primarycareprovidersareattendingphysicians,residentphysicians,physicianassistants,andnursepractitionersspecializingininternalmedicineorfamilymedicine.GFPprimarycareofficesacceptmostmajorinsuranceplans.Approximately63%ofpatientshaveprivateinsurance,22%areMedicaid-Connecticutbeneficiaries,14%haveMedicare,and2%areself-pay.Eachprimarycareofficeprovidesgeneralmedicalcare,routinehealthexams,immunizations,labtesting(includingin-officeHbA1ctesting),andreferralstospecialistsandGriffinHospitalpreventionprogramsandsupportgroups.7

GriffinHospitalservesthelowerNaugatuckValleyRegion(“theValley”)ofConnecticut,comprisedofthetownsofAnsonia,BeaconFalls,Derby,Naugatuck,Oxford,Seymour,andShelton.TheValleytownsrepresentthediversityofthe169townsinConnecticut,withsomeconsideredurbanperipherytowns(Ansonia,Derby,andNaugatuck),rural-liketowns(BeaconFallsandSeymour),andhigher-incomesuburbantowns(OxfordandShelton).

Pre-Demonstration Project Approach Priortothedemonstrationproject,therewasnopractice-widesystematicscreeningforprediabetesatGFPoffices.Screeningandreferralsweredependentuponeachprovider’sclinicaljudgment.GriffinisaCDC-recognizedorganizationandofferedtheNationalDPPlifestylechangeprogrampriortothedemonstrationproject.ReferralstothisandotherCenterforPreventionandLifestyleManagement(CPLM)programsofferedthroughtheoutpatientclinicwerehandledthroughtheEHR.Inadditiontothediabetespreventionprogram,patientswithprediabeteswerereferredtoaregistereddietitianformedicalnutritiontherapy/nutritionassessmentandmanagementasneeded.

7GriffinFacultyPhysiciansDemonstrationProject2018MidtermReport

Demonstrat ion Project GFPdesignedthedemonstrationmodeltofocuson:

• Developingpractice-widesystematicscreeningforprediabetesatGFPoffices.• Modifyingexistingpublicdomainresourcestosupporttheprediabetesscreening,testing,andreferral

model.

Provider Engagement Beforeapplyingforthedemonstrationproject,theDirectoroftheCenterforPreventionandLifestyleManagementatGriffinHospital(CenterDirector)metwithseveralkeymembersoforganizationleadershiptoobtaintheirbuy-infortheproject,particularlytheDirectorofPrimaryCareforGriffinFacultyPhysiciansandtheVicePresidentforAccountableCare.TheCenterDirectordiscussedtheproposedprogramwiththeGFPdataleadandRN/MAQualityleadwhotrainsthemedicalassistantsandhelpsensurethatqualitymeasuresaremet.Theideaofusinganewpre-visitplanningformemergedfromthesemeetings.Whendemonstrationprojectfundingwasreceived,theCenterDirectormetwiththeprimarycareproviderstoexplaintheproject,elicitedtheirfeedbackandconcerns,anddiscussedhowtoaddressthem.

AreferencesheetforprovidersandstaffwasdevelopedthatincludedinformationontheNationalDPP,thedemonstrationproject,aswellaspatientinsuranceco-payinformationthattheproviderscoulddiscusswiththepatient.Throughouttheprocess,theCenterDirectormetwiththeDirectorofPrimaryCareandcapitalizedonstrategicopportunitiestospeakwithprimarycareprovidersandstaff.

Developing Awareness GFPutilizedthefollowingmaterialstodevelopawarenessoftheprogramwithinthehospitalsystemandthecommunity(AppendixA):

• CDCNationalDPPpatientbrochures/handouts• CDCNationalDPPpostersandinfographicsinclinicrooms• CDCNationalDPPoverviewinformationforproviders

ThematerialspromotedawarenessofprediabetesandtheNationalDPPamongproviders/staffandpatients.Additionally,presentationswereconductedatproviderandstaffmeetingstopromoteawarenessofprediabetesandtheNationalDPP,andtoorientthemtothenewclinicworkflow.


Patient Identif ication TheGFPscreeningapproachwasamodifiedcombinationofthe“retrospectiveprediabetesidentification”andthe“point-of-careprediabetesidentification”8modelsnotedinthePreventDiabetesStatToolkit.Specifically,GFPutilizedtheplanningplatformdevelopedbyitsEHRconsultant,SymphonyRM.Forthisproject,SymphonyRMcreateda“prediabetesmodule”forthepre-visitplanning(PVP)tool.Insteadofgeneratingalistofpatientsneedingprediabetesscreening(“retrospectiveEHRquery”),thePVPformalertedprovidersoftheneedforprediabetestesting(donebythemedicalassistant;“point-of-careprediabetesidentification”),ortheneedtodiscussreferraltotheNationalDPPlifestylechangeprogramwithpatientswhometthecriteriaforprediabetes.

Theworkflowforidentifyingpatientswithprediabetesbeganwithscreeningallpatients≥45yearsofageorwithaBMI>25kg/m2(>23kg/m2inAsianAmericans).Theageof≥45wasbasedontheAmericanDiabetesAssociation’s2017StandardsofMedicalCareinDiabetescriteriafordiabetesscreening.

Screen9(1)allpatientsage≥45OR(2)withBMI≥25kg/m2(≥23kg/m2inAsianAmericans)ANDoneormoreofthefollowingriskfactors:1. Firstdegreerelativewithdiabetes2. High-riskethnicity(AfricanAmerican,Latino/Hispanic,AmericanIndian,AlaskanNative,AsianAmerican,

PacificIslander)3. Womenwithhistoryofgestationaldiabetesordeliveringababy>9pounds4. Historyofcardiovasculardisease5. Hypertensiondiagnosis6. HDLcholesterollessthan35mg/dLand/ortriglyceridelevel>250mg/dL7. Womenwithpolycysticovariansyndrome

Retrospective Query Intheretrospectiveidentification(Diagram7),theEHR/patientdatabasewasqueriedtoscreenforprediabetesamongpatientswhometthecriteria.Inthepoint-of-careidentification,ifapatientwasage18orolderanddidnothavediabetes,ascreeningtestwasadministered,andbloodglucosetestingwasordereddependentuponthepatient’srisk.

8CentersforDiseaseControlandPreventionandAmericanMedicalAssociation.Preventingtype2Diabetes:Aguidetoreferyourpatientswithprediabetestoanevidence-basedpreventionprogram(PreventDiabetesSTATtoolkit).Retrievedfromhttps://www.cdc.gov/diabetes/prevention/pdf/stat_toolkit.pdf9AmericanDiabetesAssociation.Classificationanddiagnosisofdiabetes.Sec.2.InStandardsofMedicalCareinDiabetes2017.DiabetesCare2017;40(Suppl.1):S11–S24


GFPcreateda“prediabetesmodule”forthepre-visitplanningtoolthatutilizedthecriteriabelowtogenerateanalertinthePVPformindicatingthatthepatientneedsprediabetestesting(HbA1cin-officeduringthevisit),orneedstheprovidertodiscusstheNationalDPPlifestylechangeprogramandinitiateareferral.Insteadofcreatingalistofpatientsneedingprediabetestesting,thePVPformautomaticallygeneratedanalertforprediabetestestingorreferraltotheprogramforpatientswhometthecriteriabasedontheAmericanDiabetesAssociation’s2018StandardsofDiabetesCare.

Point of Care Prediabetesscreeningandtestingwasincorporatedintothepre-visitplan.Eachtimeapatientatriskfortype2 diabetes came to the clinic, the patient record was flagged, and the provider had a discussion with thepatientatthepointofcare.

TwotypesofpatientswouldtriggerareferraltotheNationalDPPlifestylechangeprogram:(1)apatientwithanHbA1cof5.7-6.4duringthevisitOR(2)apatientwithoutapreviousHbA1cinthecurrentyearwhowasflaggedbythepre-visitplanningtoolasneedinganHbA1ctest,andsubsequentlyhadanHbA1cintheprediabetesrange(5.7-6.4).Forthesetwotypesofpatients,themedicalassistantalertedtheprimarycareprovideroftheneedtodiscusstheNationalDPPlifestylechangeprogram,andtomakeareferralintheEHRifthepatientwasinagreement.

Alternatively,ifthepatientwasnotreadytocommittotheNationalDPPorwasinterestedinotherinterventions,thePCPreferredthepatienttotheCPLMIntakeCoordinatorwhoexplainedthedifferentprogramsavailable.

ReferralstoallCenterforPreventionandLifestyleManagementprograms,includingGriffin’sCDC-recognizeddiabetespreventionprogram,wereincorporatedinthereferralsectionofGFP’soutpatientEHR,Athenanet.Whenaproviderorderedareferraltothediabetespreventionprogram,afaxwassenttotheGriffinHospitalDiabetesEducatorandDiabetesPreventionProgramFacilitatorwhocontactedthepatientregardingenrollingintheprogram.GFPalsoupdatedtheEHRtotrackwhenaproviderdiscussedareferraltothediabetespreventionprogramandthepatientwasnotreadytocommit.


Pre-Visit Planning Whendesigningthescreeningprotocol,GFPaddedelementsthatwerealreadyinplaceintheirclinicworkflowateachGFPoffice.AspartofPatientCenteredMedicalHomecertification,eachofficeutilizedapre-visitplanningtool/formthatflagsfortheofficestaffwhatneedstobedoneforeachpatientathis/herupcomingvisit.Priortothedemonstrationproject,thepre-visitplanningtool/formdidnotflagpatientswhowereatriskfortype2diabetesforprediabetesscreeningortesting.

Diagram 7. GFP Retrospective Prediabetes Identification Process

Generate a l ist of patient names with relevant information

*BMIcriteriahavechanged(now>25,or>23ifAsian)Source:PrediabetesSTATToolkit,AMA/CDC

Successes, Challenges, and Lessons Learned GFPdidnotmoveforwardwiththescreeningandreferralprocessfortheNationalDPPlifestylechangeprogram.Therewasadelayinimplementingtheprediabetesmoduleofthepre-visitplanningform/toolduetoconcernsraisedbyproviders(e.g.,financialburdenofthebloodglucosetestonpatients,inconsistentproviderknowledgeandcomfortwithICDcodestoensureHbA1ctestingiscovered,andtimingofthetesting),whichGFPhasaddressed.

- Current diagnosis of diabetes (ICD-9: 259.xx) or - Current insulin use

b. Exclus ion cr iteria:

o OGTT 140-199 mg/dl (LOINC code 62856-0) or - History of gestational diabetes (ICD-9: V12.21)

o FPG 100-125 mg/dl LOINC code 1558-6) or o HbA1c 5.7 - 6.4% (LOINC code 4548-4) or

- A Positive lab test result within previous 12 months: - Most recent BMI ≥ 24* (≥22 if Asian) and - Age ≥ 18 years and

a. Inc lusion cr iteria:

Query EHR or patient database every 6-12 months us ing the fol lowing cr iteria:

Measure

- Program Coordinator wil l contact patient directly, and

c. Flag medical record for patient’s next office v isit

b. Send patient info to diabetes prevention program provider

a. Contact patients to inform of risk s tatus, explain prediabetes , and share info on diabetes prevention programs, and/or

Use the pat ient list to:

Act

Discuss program participat ion at next visit

GFPfirstwantedtoaddressproviderconcernsbeforemovingforwardwiththeprediabetesmoduleoftheirpre-visitplanningform,sothatstaffandprovidersareengagedandunderstandthatGFPvaluestheirfeedbackandwantstopartnerwiththemthroughouttheprocess.Duetothisaim,therewerenoreferralsorenrollmentintheNationalDPPlifestylechangeprogramduringthedemonstrationproject.

30

Partner

Onelessonlearnedfromthisprojectwasthatitisessentialtousethe“teach-backmethod”toensurethesoftwarevendorcandeveloptheneededsystemenhancements.Themethodconsistsofaskingtheconsultant/softwaredeveloperto“teachback”/sharetheirunderstandingofthealgorithm.Anotherlessonistomakesurethereisdirectcommunicationwiththeindividualresponsibleforwritingthecode.Asaresultofthesechallenges,GFPpreferredtodelaylaunchingtheprocess,bothtoensureaccuracyofresultsforpatientsandalsocontinuedandsustainedbuy-infromthestaffandproviders.

Three key lessons learned during the GFP demonstration project were: 1. Createandpromoteacollaborativeprocess:

-Empowerstakeholdersintheprocess(listen,iteratefromfeedback,monitor).-Useandmaximizeexistingtools.

2. DemystifytheNationalDPP,andshowcasethepoweroflifestylechange:-Narrativesarepowerful.-Emphasizepatientempowerment.

3. FacilitateeaseofreferralandenrollmentintheNationalDPPlifestylechangeprogram:-IncorporateaprocessforreferralwithintheEHR.-Identifypointsofcontact(forpatientsandproviders).

Whiletherewerechallenges,GFPalsohadsuccessesthroughouttheprocess:PrediabetesInformationSession:Theprediabetesinformationsessionisacommunity-basedinformationsessionwhereparticipantslearnaboutprediabetesandtheNationalDPP.Thesessionwasverywell-receivedbyparticipatingpatientsandthecommunity.GFPplanstohostatleasttwosessionsperyeartoincreasepatientandcommunityawarenessofprediabetesandtheNationalDPPlifestylechangeprogram.GFP’sgoalwastodemystifyprediabetesandtheNationalDPPandencourageandempowerpatientstomakelifestylechangesthathelppreventtype2diabetes.Sessionparticipantsnotedenjoyingbeingabletolearnaboutthepathophysiologyofdiabetes(“mini-medschool”lesson),beingabletoaskpracticalquestionsabouthealthynutrition/lifestylechange,hearingfromindividualswhosuccessfullycompletedtheNationalDPPlifestylechangeprogram,andbeingabletoaskspecificquestionsabouttheprogramcomponentsanditslength.

Scalability and Next Steps ThedifferentcomponentsofthedemonstrationprojectarenowembeddedintheclinicsysteminawaythatwillpromoteawarenessofprediabetesandtheNationalDPPamongpatientsandthecommunity,increasedetectionofprediabetesusingthepre-visitplanningtool(continuingtoiterateandmakesureitisaccurate),includetheseprocessesintheworkflowofthemedicalassistantandtheprimarycareprovider,andcontinuetomaintainbuy-infromtheDirectorofPrimaryCareandotherleadershipandstaffatGFP.Forthelatter,theDirectorcontinuestomeetwithtrainers/qualitycareleadsaswellaswiththeDirectorofPrimaryCareandthemaincontactpersonatSymphonyRM(theconsultantswhodevelopedthepre-visitplanningtool,)andattendsprimarycareprovidermeetingstocontinuetoeducateontheprocess.Additionally,residentsarerequiredtoreviewinformationonallCPLMprograms.


Learningfromthisdemonstrationproject,GFPwillcontinuetoincreasepatientawarenessofprediabetesandtheNationalDPPlifestylechangeprogramusingthefollowingmethods.• Newsletter:GFPwillhavetwonewslettercampaignsonprediabeteseachyear,onceinthespring

andonceinthefall.Thenewsletterwillbeapersonalizedletter(seeAppendixA)fromthepatient’sprimarycareprovideraddressingvarioushealthtopics,includingprediabetes(seeAppendixA).ThenewsletterwillalsoincludetheADAType2DiabetesRiskTest.GFPprimarycarenewslettersreachthewholepatientpopulationofthepracticegroup,approximately20,000patients.Allpatientswithemailaddressesonfilewillreceivethenewsletterviaemailblast.

• TargetedEmailBlast:Inadditiontothenewsletter,GFPhasfoundthatatargetedemailblastisanothermeanstoincreaseawarenessaboutprediabetesandrelatedinformationsessions,especiallywhentimedappropriately.

• PrediabetesInformationSession:ThisisaparticularlypowerfulwayofincreasingpatientawarenessandcomfortwithsigningupfortheNationalDPPlifestylechangeprogram.Themaingoalofthesesessionsistoempowerpatientswithknowledgethattype2diabetescanbepreventedwithlifestylechange,andthatothershavesucceededinreducingtheirriskthroughtheNationalDPPlifestylechangeprogram.GFPanticipates10-40communitymembersperinformationsession.

AnothergoalistodemystifytheNationalDPPlifestylechangeprogram.Movingforward,GFPwillkeeptheformatoftheinformationsessionusedduringthedemonstrationproject:• Duration:1hour(mimicsthelengthofaNationalDPPlifestylechangeprogramclasssession)• Topics/sectionscoveredduringthesession:

• Prediabetes/diabetesandlifestylechange(speaker(s):internalmedicine/preventivemedicinephysiciansand/orprimarycarephysician)

• TheNationalDPPlifestylechangeprogramanditscomponents(speaker:diabeteseducator)• TheNationalDPPexperienceandlong-termchange/testimonial(speaker(s):1-2program

graduates)


Summary of Challenges

Thegranteesfacedanumberofchallengesandhaveuncoveredanumberofvaluablelessonslearned.Someencountereddelaysinimplementationduetoconcernsraisedbyproviders.TheconcernsincludedthefinancialburdenofbloodglucosetestingonpatientsandlimitedknowledgeandlackofcomfortwithrelevantICDcodestoensureHbA1ctestingiscovered.

Moreover,thereweredelaysinestablishingpartnershipswithkeystakeholders,suchaslocaldepartmentsofhealth,tocollaborateonpromotingtheNationalDPPlifestylechangeprogram,insomecasesbecauseofthetimeittooktoidentifythedecisionmakersandappropriateleaderswhocouldprovidetheneededsupport.ThegranteesalsoexperienceddifficultiesadjustingEHRsoftwareprogramstoincludethenecessaryworkflowtosupportprediabetesscreening,testing,andreferralandtoaddressbillingissuesforscreeningandtesting.

Retrospectivequeriestoidentifypatientsathighriskfortype2diabetestookmoretimethanexpectedduetoanumberofreasons.Forexample,onegranteehadtoconductin-depthchartreviewstoobtaincompleteinformationtodeterminewhetherpatientsmetprogrameligibilitycriteria.Insomecases,patientswereconfusedduetolackofcommunicationpriortocurrentoutreachefforts.intheprogramOutreachcallswereunwelcomeorincompleteifstaffwereunabletoleavethepatientavoicemail,orifthephonenumberwaswrongorwasoutofservice.Infact,agenerallackofpatientawarenessofprediabetes/diabeteswasfound.Therewasalsoalackofproviderawarenessoftheimportanceofprediabetesscreening,testing,andreferraltoaCDC-recognizedorganizationofferingtheNationalDPPlifestylechangeprogram.

Somepatientportalsystemsrequiredtoomanystepsforpatientstogetintothesystemtocompleteariskassessment.Inaddition,therewereconcernsaboutaskingpatientstofillout“onemorequestionnaire,”andconcernsoverHIPPAcomplianceissues.

Thechallengeofaddressingmanyitemsatthepatientappointmentattimesdetractedfromthescreening,testing,andreferralprocess.

Evenaslocalchampionssupportedprogramefforts,theyencounteredchallengesinmakingtheNationalDPPlifestylechangeprogramanongoingpriorityamongothercompetingpriorities.


Summary of Successes

As a result of conducting these demonstration projects, grantees identified several promising practices forproviders and clinical systems. These practices i speak to the similarities in health care delivery despitevariationsinpatientpopulations,organizationtype,orinsurancecoverageacrossthedifferentlocations.

GiventheprevalenceofprediabetesanddiabetesintheUnitedStates,atype2diabetesriskassessmentneedstobeincorporatedintotheroutine,standardworkflowofclinicstaffservingpopulationsathighrisk.Onceaworkflowisrepeatedmanytimesandbecomesroutine,itiseasierforstafftoimplement,anditismorelikelytobeimplementedcorrectly.Giventhemanycompetingdemandsduringaprimarycarevisit,itisallthemoreimportantthattheriskassessmentbecomemoreofaroutine,baselinetaskthatiscomfortableforallstaff–notunlikeweighingthepatient,takingbloodpressure,oraskingabouttobaccouse.

Ideally,theproviderisawareoftheriskassessment,incorporatestheinformationintothepatientchart,andactsontheresultsinawaythattherapeuticallysupportspatientaccesstoevidence-basedprevention,includingareferraltotheNationalDPPlifestylechangeprogram.However,becauseaproviderreferralisnotarequirementforparticipationintheNationalDPP,itisalsoidealthattheprovidernotactasabarriertopatientaccess.Thus,ifapatientmeetsthecriteriaforreferralviatheirriskassessmentscore,thepatientshouldbereferredtoaCDC-recognizedorganization,evenifthepatientandproviderdonothavetimetodiscussthereferral–whichmaybealltoocommonduringabusyclinicvisit.Thus,othersupportstaffshouldbeempoweredtoreferpatientswhomeetprogrameligibilitycriteria.Dependingonstatelicenseregulations,alliedhealthprofessionalsmaybeempoweredtoorderappropriatebloodglucosetesting,ifneeded.Theuseof“standingorders,”writtenofficeprotocols,orotherstandardworkflowdocumentshelpclarifyexpectationsinateam-basedcareand/ormultidisciplinaryclinicenvironment,andsupportongoingqualityassuranceandqualityimprovementexercises.

Empoweringalternatestafftoassistinscreeningandreferralsalsocreatesopportunitiesforthesestafftoscreenandreferwhentheyinteractwithpatientsoutsideofthetraditionalofficevisit.Examplesofsuchinteractionsincludewhenpatientscallforappointments,areremindedaboutappointments,aregivenresultsoverthephone,orcomeinforotherservicessuchasimmunizationsorfluvaccines.Theseinteractionsmightbefurthersupportedwithstandardscriptsorhealtheducationmaterialsthatcanbeusedbyalliedhealthstaff.Themanyinteractionsthatthesestaffhavewithpatientsoutsideofthetraditionalofficevisitusuallyinvolvedocumentation,whichaffordsanopportunitytoreviewbasicinformationintheEHRthatcanbehelpfulincompletingatype2diabetesriskassessment(e.g.age,race/ethnicity,pastmedicalhistory[i.e.gestationaldiabetes],currentproblemlist[highbloodpressure,obesity,etc.],familyhistoryoftype2diabetes,BMI,andperhapsevenbloodglucosevalues).Thus,ariskassessmentmaybeeasilycompletedonbehalfofapatientorcompletedwithveryfewquestions.IdentifyingeligiblepatientsmaythenautomaticallypromptareferraltoaCDC-recognizedorganizationoraproviderappointmenttodiscusstype2diabetesrisk.

Eveninaclinicthatemploysatype2diabetesriskassessmentasapartofthestandardworkflowduringpatientregistrationorrooming,therewillbemissedopportunitieswhentheriskassessmentorreferralisforgotten,misplaced,misunderstoodbythepatient,misinterpretedbystaff,ornotcarriedoutbecausethepatientsimplydoesnotpresentattheclinic.Empoweringalliedhealthorsupportstafftoemployaprotocol/standardworkflowinavarietyofsettingsoracrossmultiplepatientinteractionshelpsensurecompletionofthetask,despitehumanerror.

Aswithotheressentialhealthcareservices,qualityassurancetoolsandregularchecksshouldbebuiltintotheprocess.Standardworkflowdocumentsand/orprotocolsareessentialfortrainingandreference.Checklistsanddocumentationtools,includingpreformattednotetemplatesortextmacrosforanEHR(e.g.“smartphrases”or“dotphrases”),arealsohelpfulfortheday-to-dayworkofinteractingwithpatientsanddocumentingintheEHR.Theteamneedstoconductqualityassurancereviewsofdatagathered,suchasverifyingheightandweightandcheckingforfamilyhistoryupdates.Identifyingandcollectingdatarelatedtothegoalofthisproject(increasingprediabetesscreening,testing,andreferraltoaCDC-recognizedorganization)–andthenreviewingthesedataatregularintervals–isnotapartofroutineworkatmostclinics.Howevercollectingandreviewingsuchdataisintegraltoanyqualityimprovementeffort.

35

Focusingonwrittenprocessesandworkflowstoimprovetheefficiencyorexpediencyofprediabetesscreening,testing,andreferralisalsoessential.Forexample,theprocessofcheckingforpatienteligibilitycriteriaviaachartreviewmaybeexpeditedbyutilizingthebulkmessagingfunctionwithintheEHRtogeneratelettersappropriately.EHRsystemsthatsupportthehealthteamcanmakeatremendousdifferenceintermsofcollatingandprovidingcriticalinformationandremindersatthepointofcare.SomeEHRscanbesetuptocalculateriskautomaticallyandcreateremindersoralertsinthepatient’schart.SupportstaffandproviderscanbetrainedontheserelevantfieldsandfunctionalitywithintheEHR.WorkflowscanbedevelopedthatallowstaffmembersotherthanphysicianstoassistinidentifyingpatientseligiblefortheNationalDPPlifestylechangeprogram,initiatingreferrals,andcommunicatingwithprimarycareprovidersaboutthesereferrals.

Effectivecommunicationamongallmembersofthehealthcareteamnotonlyhelpsinitiatenewworkflows,butcanalsohelpinformadjustmentstoimproveexistingworkflows,makingthemsustainableandsuccessfuloverthelongterm.Examplesofeffectivecommunicationincludethefollowing:

1. Conductingmeetingswithmedicalleadership,qualityimprovementleaders,clinical“champions”fromdifferentdisciplines,andmanagers/trainersformedicalassistantsandotheralliedhealthstafftoensureleadershipandmanagementsupport.

2. Conductingpresentationsforprovidersatbothregularclinic-levelmeetingsandspecialeducationaleventsfocusedoncontinuingeducationorqualityimprovement.

3. Holdinginitialmeetingstoeducateallmembersofthehealthcareteamandtoelicittheirconcernsandinputonanydesiredchangesinworkflow.

4. Providingupdatesatregularintervalsonthesuccessesandchallengesandimprovementideasfortheworkflowaftertheprojecthasbegun.

5. Leveragingexistinghealthsystemandhealthteamcommunicationportals,includingmeetings,newsletters/publications,emails,andmailerstopatientsand/orstaff/employees.

Beforeinitiatingaprediabetesscreening,testing,andreferraleffort,thehealthsystemorclinicmustidentifyamultidisciplinaryteamofNationalDPP“champions”whowillhelppromotetheprogramandsupporteffortstoimplementsystematicscreening,testing,andreferralprotocols.ThesechampionsneedtoverifythatpatientshaveaccesstoaCDC-recognizedorganizationofferingclasseslocallyoronline,andthattheseprogramscanmeettheneedsofpatientsinareasonabletimeframe.ThiscanbedonebysettingupregularcommunicationwithactiveCDC-recognizedorganizationsservingyourtargetpopulation.Championsmustalsoactivelypromotetheprogram;conductongoingprediabetesinformationsessions;continuallyanswerquestionsandhelptroubleshoot;andprovidereferencematerialsappropriateforproviders,staff,andpatients.Effectivecommunicationandcollaborationwithproviders,staff,administrators,andconsultantsiscrucial,andmustincludetakingtimetoaddresstheconcernsofkeystakeholders.


Table 3. Summary of Challenges and Lessons Learned

Pro

vid

er

Co

nce

rns

Chal lenges Key Lessons Learned • The financial burden of HbA1c testing on

patients, and limited knowledge and lack of comfort with relevant ICD codes to ensure the cost of HbA1c screening is covered

• Making the National DPP lifestyle change program an ongoing priority among other competing priorities

• Concerns over HIPPA compliance issues

• Effective collaboration is a must; take time to address the concerns of key stakeholders.

De

lays

• Delays in implementation due to provider concerns

• Delays in establishing partnerships with key stakeholders, such as local departments of health to collaborate on promoting the program

• Look at steps that can minimize delays (e.g. minimizing chart review time by utilizing the bulk messaging function within the EHR to generate letters).

Co

mm

un

icat

ion

/A

war

en

ess

• A general lack of patient awareness of prediabetes/diabetes

• Lack of provider awareness of the importance of prediabetes screening, testing, and referral to a CDC-recognized organization offering the National DPP lifestyle change program

• Communication and education for both patients and providers is essential.

• Provider education is necessary to introduce the National DPP and explain how to utilize the risk score in screening patients for type 2 diabetes.

• To assure system-wide change occurs, local champions must get buy-in from senior leadership, as well as from staff and primary care providers.

• Champions must also promote the necessary materials and tools for providers and staff to use.

Tech

no

logy

• Difficulties adjusting EHR software programs to include the necessary workflow and to address billing issues for screening / testing.

• Patient portal systems requiring too many steps for the patient to get into the system to complete a risk assessment.

• Electronic systems can be set up to calculate risk automatically and place an alert in the health maintenance field.

• Train staff on any new, relevant fields created within the EHR.

• Incorporate referral functionality within the EHR.

Pro

cess

es

and

W

ork

flo

ws

• Recruitment processes, such as retrospective queries, requiring more time than expected

• Addressing many items during the patient appointment detracting from the screening, testing, and referral process.

• Providers challenges in adjusting to new workflows.

• Workflows can be developed that allow staff members other than primary care providers to assist in prediabetes screening, testing, and referral.

• Incorporate screening, testing, and referral protocols into the regular work flow of primary care providers and allied health staff.

• Verify that patients have access to CDC-recognized organizations offering classes locally or online.

• Identify key points of contact for patients and providers.


Conclusion

Inatwo-yearprojectfocusedonstrengtheningandinstitutionalizingpracticestosupportprediabetesscreening,testing,andreferraltoCDC-recognizedorganizationsofferingtheNationalDPPlifestylechangeprogram,theAmericanCollegeofPreventiveMedicineworkedwithninehealthcareorganizations/practices.

Threeoftheseorganizationswerehighlightedinthiscasestudy,whichreviewedtheirapproaches,barriers,andscalabilityplans:• NortheastMissouriHealthCenter–Kirksville,Missouri(FQHC)• AccentonHealth–Washington,DC(IPA)• GriffinFacultyAssociates–Derby,Connecticut(IPA)

Thegoalssetoutfortheprojectweretoincreasephysicians’/healthcareprofessionals’awarenessofprediabetesasaserioushealthcondition;developandimplementprotocolsforscreening,testing,andreferringpatientswithprediabetestoaCDC-recognizedorganization;andincreasethenumberofphysicians/healthcareprofessionalstakingactiontoscreen,test,andreferpatientswithprediabetestoCDC-recognizedorganizations(organizationswithpending,preliminary,orfullrecognition).

ChallengesandlessonslearnedfromtheNortheastMissouriHealthCenterinclude:• Additionaltrainingsprovidedopportunitiesfornursesandstafftoaskquestionsabouttheriskfactors

contributingtothedevelopmentoftype2diabetes.• Type2diabetesriskassessmentmaynotbethehighestconcernforthepatientorproviderattheinitial

appointmentwithaprimarycareprovider.

• Addingscreeningsornewinformationtoanexistingworkflowinthealreadylimitedtimeofatypicalclinicappointmentcanbechallenging.Workflowsweredevelopedtoallowotherstaffmemberstoassistinidentifyingpatientsforreferralandcommunicatingthisinformationtotheproviders.


ChallengesandlessonslearnedfromAccentonHealthinclude:• Thesoftwareusedintheenrollmentprocessmayhavelimitedidentificationandreferralofpatients

withprediabetes,becauseitwasnotdesignedtoincorporateprediabetesscreeningintotheEHR.Accentidentifiedtheneedforanewsoftwareprogramandamoreexperiencedteamtohandlebillingquestionsandconcerns.

• Therewerechallengeswithreimbursementforbloodglucose(HbA1c)testing.• LocaldepartmentsofhealthneedtobeinvolvedearlyintheprocesstoassistinpromotingtheNational

DPP.Peerleadersanddiabeteseducatorscanalsohelpinpromotingtheprogram.

ChallengesandlessonslearnedfromtheGriffinFacultyAssociatesPrograminclude:

• InordertofacilitateeaseofreferralandenrollmentintheNationalDPPlifestylechangeprogram,referralfunctionalityisneededwithintheEHR.

• The“teach-backmethod”isnecessarytoensurethesoftwarevendorcandevelopneededsystemenhancements.Directcommunicationwiththeindividualresponsibleforwritingthecodeisalsocritical.

• Acollaborativeprocessisnecessarytoempowerstakeholdersintheprocessanduseandmaximizeexistingtools.

• NarrativesarepowerfulandcanemphasizepatientempowermenttodemystifytheNationalDPPandshowcasethepoweroflifestylechange.

Insummary,thecasestudyfoundthatchallengesandbestpracticesweresimilardespitethediversityamongparticipatinghealthcaresystems/practicesingeographiclocation,patientpopulations,andinsurancecoverage.Providerconcerns,delays,communication/awareness,technology,andprocesses/workflowwerethekeyareasidentifiedandaddressedbythehealthcareorganizationsinthiscasestudy.

Notably,improvedcommunicationandworkflowswereidentifiedastwomainthreadsacrossalltherecommendationsandpromisingpractices.Increasedandimprovedcollaborationbetweenprovidersisessentialtosystem-wideadoptionofnewworkflows.CommunicationandeducationforbothpatientsandprovidersisessentialandcancomewithadoptionofnewtechnologyandtoolsavailablethroughEHRs.Also,forsuccessfulprograms,championsareneeded.Championsareoftenkeyleadershipataclinicorhealthorganizationandareintegraltoincreasingbuy-infromalllevelswithintheorganization,promotingtheuseofnewmaterialsandimplementingandsupportingnewworkflowsandprocesses.


Resources

Centers for Disease Control and Prevention (CDC) 1. CDC National Diabetes Prevention Program - https://www.cdc.gov/diabetes/prevention/index.html 2. What Is the National DPP? - https://www.cdc.gov/diabetes/prevention/about/index.html 3. Implement a Lifestyle Change Program (for Professionals) -

https://www.cdc.gov/diabetes/prevention/lifestyle-program/index.html 4. Screen & Refer Patients to a Lifestyle Change Program (for Professionals)-

https://www.cdc.gov/diabetes/prevention/lifestyle-program/deliverers/index.html

5. Requirements for CDC Recognition - https://www.cdc.gov/diabetes/prevention/lifestyle-program/requirements.html

6. =

American College of Preventive Medicine (ACPM) 7. Diabetes Prevention Program Resource Center- https://www.acpm.org/page/dppresources 8. ACPM Diabetes Prevention Program Initiatives – www.acpm.org/page/dpp

Centers for Medicare & Medicaid Services (CMS) 9. Medicare Diabetes Prevention Program website - https://innovation.cms.gov/initiatives/medicare-diabetes-

prevention-program/ 10. Medicare Diabetes Prevention Program (MDPP) Medicare Advantage Fact Sheet -

https://innovation.cms.gov/Files/fact-sheet/mdpp-ma-fs.pdf 11. Medicare Diabetes Prevention Program (MDPP) Expanded Model Fact Sheet -

https://innovation.cms.gov/Files/x/MDPP_Overview_Fact_Sheet.pdf

American Medical Association (AMA) 12. Preventing Type 2 Diabetes - https://www.ama-assn.org/delivering-care/preventing-diabetes 13. Prevent Diabetes STAT™ Toolkit - https://preventdiabetesstat.org/toolkit.html 14. What Physicians Can Do to Prevent Diabetes - https://www.ama-assn.org/delivering-care/advocating-

diabetes-prevention#What%20Physicians%20Can%20Do%20to%20Prevent%20Diabetes

American Diabetes Association (ADA) 15. Diagnosing Diabetes and Learning About Prediabetes- http://www.diabetes.org/are-you-at-

risk/prediabetes/?loc=atrisk-slabnav 16. Type 2 Diabetes Risk Test - http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/ 17. Tools to Know Your Risk- http://www.diabetes.org/are-you-at-risk/tools-to-know-your-risk/?loc=atrisk-

slabnav 18. Practice Resources - http://www.diabetes.org/research-and-practice/practice-resources/?loc=rp-slabnav

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 19. Diabetes Prevention Program (DPP) - https://www.niddk.nih.gov/about-niddk/research-

areas/diabetes/diabetes-prevention-program-dpp 20. Preventing Type 2 Diabetes - https://www.niddk.nih.gov/health-

information/diabetes/overview/preventing-type-2-diabetes


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