2019 Diabetes Program Evaluation...• During the measurement year, increase clinician adherence to...

Our mission is to improve the health and quality of life of our members

2019 Diabetes

Program Evaluation

2019 Diabetes Program Evaluation

Table of Contents

Program Purpose Page 1

Program Goals Page 1

Program Objectives Pages 1-2

Measurements

Evaluation

Annual Participation Rates Page 2

Diabetes Member Engagement Page 3

Diabetes Management HEDIS® Results Pages 3-6

Analysis of Findings Pages 7-8

Number of Referrals by Source Page 9

Member Discharge Status Page 10

Emergency, Admission and Readmission Utilization Page 11

Diabetes Cost Trends Page 12

Overall Financial Impact for Identified Sample of Diabetes Members Page 13

Goals Met/Not Met Page 14

Diabetes Care Gaps Pages 15-16

Member Satisfaction Survey Results with Services Received Pages 16-17

Member Satisfaction Survey Results for Improvement of Health or Quality of Life Page 17

Barriers/Opportunities Page 18

Activities Pages 19-21

3/3/20 FINAL Page 1 of 21

2019 Diabetes Program Evaluation

Program Title: Diabetes Program

Evaluation Period: January 1, 2019 – December 31, 2019

Program Purpose: The Diabetes Program is a system of coordinated healthcare interventions and communications for a population with a condition in which patient self-care efforts are significant. Adherence to evidence-based medicine combined with a team approach assist in: • Empowering members

• Supporting behavior modification

• Reducing incidence of complications

• Improving physical functioning

• Improving emotional well-being

• Supporting the clinician/patient relationship

• Emphasizing and reinforcing use of clinical practice guidelines

Program Goals: The goal of the Diabetes Program is to effectively identify members at risk of potentially avoidable episodes of care and intervene to positively impact the health outcomes and quality of life for members with Diabetes. By using a multi-faceted approach to achieve the best possible outcomes the Diabetes Program can lower costs through preventing avoidable episodes of care and better coordination of care. Program goals include: • Partner with members, their caregiver and their primary and specialty care

clinicians to develop a plan of care or action plan by a Health Educator

• Improve medication adherence

• Facilitate appropriate communication across the entire care team

• Optimize diabetes management and close relevant gaps in evidence-based care

• Educate patients on their diabetes diagnosis and self-management

Program Objectives: • During the measurement year, increase clinician adherence to American Diabetes Association (ADA) Standards of Care and the percentage of members receiving: o At least one Hemoglobin A1c (HbA1c) test o A Dilated Retinal Eye (DRE) Exam o Medical attention for nephropathy o Statin therapy and adherence


• Increase the percentage of members with: o HbA1c good control of < 7% o HbA1c good control of < 8% o Blood pressure (BP) level of < 140/90 mm Hg

• Decrease the percentage of members with:

o HbA1c poor control of > 9% o Inpatient admissions o Readmissions within 30 days o Emergency room (ER) visits

• Promote healthy lifestyle, diet and nutrition, measurement of blood sugars

as prescribed by the clinician, adherence to medication regimen, weight management, physical activity, smoking cessation, and adherence to recommended screenings/tests through targeted telephonic and educational mailings.

Measurements: Overall effectiveness of the program is measured through annual participation

rates and audited HEDIS®1 results.

Annual Participation Rate Eligible members are identified and passively enrolled in the Diabetes Program. Members may “opt out” of the Program and elect not to receive services, by notifying a Health Educator or the Care Connector Program, either telephonically or in writing. Participation Rates are tracked and reported annually.

Graph 1.

1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

31 25

54 63 55 52

26 2643

16 18 23

56

116

191

256

214 218

97

37

101

176

56

1313 16 19 21 13 18 7 4 7 14 5 1

January February March April May June July August September October November December

Members Engaged Members Identified Declined Participation

28.22% Participation


Member Engagement Health Educators engaged 432 members in 2019. This represents a 57% increase from 2018. Members appropriate for this program have a diagnosis of diabetes. Health Educators work with the members to decrease readmissions and ER utilization and to increase utilization of outpatient services and compliance with treatment and care plans.

Graph 2.

Diabetes Management

HEDIS® Results

The 2019 HEDIS® Results are based on measurement year 2018 data.

1. Comprehensive Diabetes Care (CDC) The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following: • HbA1c Testing • DRE Exam Performed • HbA1c Poorly Controlled (> 9.0%)2 • Medical Attention for Nephropathy • HbA1c Good Control (< 7.0%) • BP Control < 140/90 mm Hg • HbA1c Good Control (< 8.0%)

2 This is an inverted rate with a lower rate indicating better performance.

22

30

25

15

2522

25

20 20

35

25

14

31

25

54

63

5552

26 26

43

1618

23

January February March April May June July August September October November December

Member Engagement for Diabetes Program2018 vs. 2019 (January through December)

2018 2019


Findings: In measurement year 2018, a total of 15,785 members were identified with diabetes. A systemic sample of 548 members showed 482 (87.96%) received HbA1c testing, 321 (58.58%) received HbA1c Poor Control (> 9.0%)2, 184 (33.58%) received HbA1c Good Control (< 8.0%), 223 (40.69%) had a DRE Exam Performed, 485 (88.50%) received Medical Attention for Nephropathy, and 287 (52.37%) received BP Control < 140/90 mm Hg. Through additional required exclusion criteria, 14,742 members were identified for HbA1c Good Control (< 7.0%). A systemic sample of 514 members showed 125 (24.32%) received this indicator.

Graph 3. Graph 4.

Graph 5. Graph 6.

75.00%

77.00%

79.00%

81.00%

83.00%

85.00%

87.00%

89.00%

91.00%

93.00%

HBA1C TESTING

83.19%

86.73% 86.31%

87.96%

Comprehensive Diabetes Care

MY 2015 MY 2016 MY 2017 MY 2018

Goal 92.94%

2.00%

12.00%

22.00%

32.00%

42.00%

52.00%

62.00%

HBA1C POOR CONTROL (> 9.0%)

45.42%

37.15%

56.93% 58.58%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 27.98%

16.00%

21.00%

26.00%

31.00%

36.00%

41.00%

46.00%

51.00%

56.00%

61.00%

HBA1C GOOD CONTROL (< 8.0%)

45.42%

50.91%

34.67% 33.58%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 60.77%

2.00%

7.00%

12.00%

17.00%

22.00%

27.00%

32.00%

37.00%

42.00%

HBA1C GOOD CONTROL (< 7.0%)

31.94%

38.70%

23.98% 24.32%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 41.69%


Graph 7. Graph 8. Graph 9. The goal to meet or exceed the 2019 Quality Compass®3 90th Percentile for all CDC measures was not met (HbA1c Testing 92.94%; HbA1c Poor Control (> 9.0%)2 27.98%; HbA1c Good Control (< 8.0%) 60.77%; HbA1c Good Control (< 7.0%) 41.69%; DRE Exam Performed 69.53%; Medical Attention for Nephropathy 93.43%; and BP Controlled < 140/90 mm Hg 77.17%).

3 The source for data contained in this publication is Quality Compass® 2019 (Medicaid) and is used with the permission of the NCQA. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass® is a registered trademark of NCQA.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

DRE EXAM PERFORMED

44.93%42.62% 44.53%

40.69%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 69.53%

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

MEDICAL ATTENTION FOR NEPHROPATHY

90.68%90.05% 89.78%

88.50%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 93.43%

28.00%

33.00%

38.00%

43.00%

48.00%

53.00%

58.00%

63.00%

68.00%

73.00%

78.00%

BP CONTROLLED < 140/90 MM HG

58.07%

65.01%

52.37% 52.37%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 77.17%


Four (4) CDC measures (HbA1c Poor Control (> 9.0%)2, Good Control (< 7.0%), Medical Attention for Nephropathy, and BP Controlled < 140/90 mm Hg) met the 2019 Quality Compass® 10th Percentile, two (2) CDC measures (HbA1c Good Control (< 8.0%), and DRE Exam Performed) met the 2019 Quality Compass® 5th Percentile, and one (1) CDC measure (HbA1c Testing) met the 2019 Quality Compass® 33.33rd Percentile.

2. Statin Therapy for Patients with Diabetes (SPD)

The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria:

• Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year.

• Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period.

Findings: In measurement year 2018, a total of 8,093 members were identified as needing a statin medication. Of those members, 4,315 (53.32%) received a statin therapy and 2,505 (58.05%) of the 4,315 members had 80% adherence.

Graph 10. Graph 11. The goal to meet or exceed the 2019 Quality Compass®4 90th Percentile for SPD Received Statin Therapy (70.19%) and SPD Statin Adherence 80% (71.00%) were not met. SPD Received Statin Therapy met the 2019 Quality Compass® 5th Percentile and SPD Statin Adherence 80% met the 2019 Quality Compass® 25th Percentile.

4 The source for data contained in this publication is Quality Compass® 2019 (Medicaid) and is used with the permission of the NCQA. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass® is a registered trademark of NCQA.

26.00%

31.00%

36.00%

41.00%

46.00%

51.00%

56.00%

61.00%

66.00%

71.00%

RECEIVED STATIN THERAPY

62.38%59.76% 59.68%

53.32%

Statin Therapy for Patients with Diabetes

MY 2015 MY 2016 MY 2017 MY 2018

Goal 70.19%

37.00%

42.00%

47.00%

52.00%

57.00%

62.00%

67.00%

72.00%

STATIN ADHERENCE 80%

59.29%

46.46%

66.75%

58.05%

Statin Therapy for Patients with Diabetes

MY 2015 MY 2016 MY 2017 MY 2018

Goal 71.00%


Analysis

HEDIS®: Passport aspires to be in the Quality Compass® 90th Percentile for each measure. In MY 2018 none of the measures achieved the 90th Percentile. One (1) measure achieved the Quality Compass® 33.33rd Percentile: • HbA1c Testing

Four (4) measures achieved the Quality Compass® 10th Percentile: • HbA1c Poor Control (> 9.0%)2 • Good Control (< 7.0%) • Medical Attention for Nephropathy • BP Controlled < 140/90 mm Hg

Two (2) measures achieved the Quality Compass® 5th Percentile: • HbA1c Good Control (< 8.0%) • DRE Exam Performed

Specific results include: • Three (3) of the seven (7) CDC measures noted an increase from the previous measurement

year: o HbA1c Testing had an increase of 1.651 percentage points o HbA1c Poor Control (> 9.0%)2 had an increase of 1.65 percentage points o HbA1c Good Control (< 7.0%) had a slight increase of 0.34 percentage points

• Three (3) of the seven (7) CDC measures noted a decrease from the previous measurement year: o HbA1c Good Control (< 8.0%) had a decrease of 1.09 percentage points o DRE Exam Performed had a decrease of 3.84 percentage points o Medical Attention for Nephropathy had a decrease of 1.28 percentage points

• One (1) of the seven (7) CDC measures noted no change from the previous measurement year: o BP Controlled < 140/90 mm Hg remained the same with no change

• The two (2) SPD measures noted a decrease from the previous measurement year:

o Received Statin Therapy had a decrease of 6.36 percentage points o Statin Adherence 80% had a decrease of 8.70 percentage points


Member Engagement: Multiple member interventions were conducted to educate the member on the importance of screenings/tests needed based on the ADA Standards of Care, including adding open care gaps to the member’s individualized care plan and developing goals in and interventions to assist the member in closing these gaps. Providers who use the Identifi Practice medical management platform can view identified care gaps in the patient record and via reports. Population Health Managers distribute, and review member care gap reports with targeted practices/groups. Member Incentive Program: Passport utilized our Member Incentive Program targeted toward increasing provider and member awareness of ADA Standards of Care recommended screenings/tests, including: • BP • Attention for Nephropathy • Foot inspection • PCP or Endocrinologist Visit • Height and Weight with Body Mass Index (BMI) • HbA1c Testing • DRE Exam Performed Members who received seven (7) of the recommended screenings/tests and returned their incentive form received a total of $50 in gift card. In 2019, 313 members received gift cards for completing their screenings/tests, an 18% decrease from 2018. Community and Provider Engagement: Providers received status updates on members enrolled in the Diabetes Program and provided reference information on the ADA Standards of Care on Passport’s website. Community activity involvement included Diabetes Coalition meetings, World Diabetes Day, and health fairs around Kentucky. Risk Stratification: During 2019, an average of 2,880 members were identified via Passport’s risk stratification tool as being appropriate for the Condition Care Diabetes program. Of those members, an average of 432 received one-on-one telephonic outreach by a Health Educator. Three separate attempts were made to contact the member. All members received an initial mailing, and high-risk members received individualized mailings based on an assessment completed by a Health Educator. Member Complaints: During 2019, there were no complaints received regarding the Diabetes Program or a Health Educator.


Referral Sources

Graph 12. Passport proactively identifies members for the Diabetes Program through multiple resource avenues. Findings: Graph 12 represents referrals by source. The top three sources were:

1) Stratification 2) Utilization Management 3) PROGRAM: Medically Frail (Medically Frail was another Passport care management program.)

Multiple avenues are used to proactively identify members for the Diabetes Program. Education and information are distributed via the Member and Provider Handbooks, Member Newsletter, New Member Packets, and Member and Provider Program brochures. Provider Request for Care Management Forms are available as well on the Passport website. Education is provided through internal department meetings and internal referrals between Care Management and Behavioral Health (BH) is encouraged. A daily report is obtained from the 24-Hour Nurse Advice Line of identified members. HRAs are utilized as a means of risk screening for the member. An attempt is made to obtain an HRA for all new members and again when health status changes.

Member Services2

Health Risk Assessment (HRA)

2

PROGRAM: Complex Care

2Physician/Provider

3

PROGRAM: Transition Care

5

PROGRAM: Medically Frail

6

Utilization Management

12

Stratification397

n = 432


Member Discharge Status

Graph 13. Passport aims to reduce the inability to sustain engagement for Diabetes members by identifying barriers and trends. Findings: Graph 13 represents reasons for member’s discharge from the Diabetes Program during 2019. The top three reasons were:

1) Closed – Problem Resolved/Goals Met 2) Closed – Lost Contact 3) Closed – Insurance Terminated

There were 251 (63%) members discharged/closed due to problems resolved/goals met; 114 (29%) members closed due to lost contact and 12 (3%) members discharged due to member insurance being terminated. Discharge reasons remains consistent with 2018.

2 2 4 5 6 12

114

251

n = 399

Closed-Unable to Reach

Closed-Not Appropriate forProgram

Closed-Discontinued/Patient

Closed-Well Managed; No NeedsIdentified

Closed-Declines Participation

Closed-Insurance Terminated

Closed-Lost Contact

Closed-Problem Resolved/GoalsMet


Emergency Department and Impatient Utilization

Graph 14. Graph 15.

Graph 16.

Passport aims to reduce the rates of inappropriate emergency department (ED) utilization, avoidable inpatient admissions, and 30-day readmissions. Findings: Graphs 14, 15, and 16 represent a sample of Diabetes members and are a comparison of ED/inpatient utilization six months prior to and six months following engagement. After program involvement during 2019, the data indicates: • A decrease in the number of members accessing the ED (-31.02%), experiencing inpatient stays

(-52.33%) and being readmitted (-64.29%). • A decrease in the number of visits to the ED (-27.59%), inpatient stays (-42.31%) and readmissions

(-45.83%).

348

252

187

129

43%30%

Prior Post

ED Utilizationn = 432

ED Visits # Members Percentage of Total Members

130

75 86

41

20% 9%Prior Post

Inpatient Utilizationn = 432

IP Visits # Members Percentage of Total Members

24

13 14

5

3% 1%

Prior Post

Readmissions within 30 Daysn = 432

Readmission Visits # Members Percentage of Total Members


Diabetes Cost Trends

Graph 17. Passport aims to reduce costs related to ED utilization, Inpatient Admission, and 30-day Readmissions. Findings: Graph 17 represents a sample of Diabetes members comparing utilization six months prior compared to six months following engagement. After program involvement during 2019, the data demonstrates: • A decrease of $49,612.02 in ED costs. • A decrease of $496,989.00 in inpatient costs. • A decrease of $131,057.79 in readmission costs.


Overall Financial Impact for Identified Sample of Diabetes Members

Graph 18. Summary: Graph 18 represents the overall financial impact for the identified sample of Diabetes members analyzing utilization six months prior compared to six months following engagement. After program involvement during 2019, the data demonstrates a potential cost savings of $677,658.81. This is not representative of the entire program, but instead only the sample for analysis. This represents what is a potentially significantly higher amount for the entire program population.

Total Cost Post CM$773,096.58

Total Cost Prior to CM$1,450,755.39

n = 432


Goals Met/Not Met

Graph 19.

Passport aims to meet or exceed a rate of 90% of care plan goals partially or completely met for members enrolled in the Diabetes Program. Findings: Graph 19 represents the status of care plan goals for members enrolled in the Diabetes Program. In 2019, 1,168 goals were “completely met/partially met.” There were a total of three (3) goals that were not met due to the member’s inability to complete them. There was a goal completion rate of 99.74% for 2019. The goal to meet or exceed the target of 90% of care plan goals partially or completely met for members enrolled in the Diabetes Program was exceeded.

3

391

777

0%

33%

66%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0

100

200

300

400

500

600

700

800

Not Met Partially Met Completely Met

2019 Total Goals 2019 Percentage


Diabetes Care Gaps

Graph 20.

Passport aims to close gaps in care for members enrolled in the Diabetes Program. Findings: Graph 20 represents the total number of care gaps for members enrolled in the Diabetes Program. In 2019, a total of 3,256 care gaps were identified. Of those, 1,889 were closed (58.01%) and 1,367 (41.99%) were still active. Below is a list of the Top 10 Closed and Active care gaps identified for members in the Diabetes Program: Top 10 Closed Care Gaps Total 1,889 Patient with diabetes: greater HbA1c control may be indicated 438 23% Patient with diabetes: statin therapy may be indicated 214 11% Patient with diabetes: HbA1c test may be indicated 172 9% Patient with diabetes: eye exam may be indicated 145 8% Preventive/ambulatory care visit may be indicated 107 6% Patient with depression may not have remained on antidepressant for at least 6 months 107 6% Patient may be nonadherent to medications for hypertension (ACE/ARB) 100 5% Patient with depression may not have remained on antidepressant for at least 12 weeks 96 5% Patient may be nonadherent to medications for cholesterol (statins) 96 5% Patient with diabetes: nephropathy screening may be indicated 83 4%

Active1,367

Closed1,889

n = 3,256


Top 10 Active Care Gaps Total 1,367 Patient with diabetes: greater blood pressure control may be indicated 277 20% Patient with diabetes: greater HbA1c control may be indicated 234 17% Patient with hypertension: greater blood pressure control may be indicated 204 15% Patient with diabetes: eye exam may be indicated 151 11% Patient with diabetes: statin therapy may be indicated 95 7% Cervical cancer screening may be indicated 93 7% BMI assessment may be indicated 83 6% Colorectal cancer screening may be indicated 72 5% Patient with diabetes: HbA1c test may be indicated 56 4% Breast cancer screening may be indicated 29 2%

Diabetes Member Satisfaction Results for Services Received

Graph 21. Passport aims to achieve or exceed a score of 90% or above in all areas of member satisfaction for the Diabetes Program. Findings: Graph 21 represents the members’ satisfaction regarding services received. The areas surveyed include: 1) Understand Health Condition 2) Professional and Courteous Manner 3) Value of Written Materials 4) Help with Making Decisions The goal was to achieve 90% satisfaction for each area. For 2019, 361 telephonic member surveys were conducted, of which 91 were completed (25% response rate). The target was not met in all areas.

93% 91% 89% 89% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UnderstandHealth Condition

Professional andCourteous Manner

Value ofWritten Materials

Help withMaking Decisions

Total

Goal 90%

n = 91


Interventions: • Upon closure of the Diabetes Program, members are encouraged to participate/provide feedback to

the survey. • Outreach is done to members who indicate via the satisfaction survey that they would like to be

contacted. Diabetes Member Satisfaction Results for Improvement of Health and Quality of Life

Graph 22. Passport aims to maintain or exceed the goal of 75% or above in member's perception of improved overall health status and quality of life. Findings: Graph 22 represents the members’ satisfaction regarding improvement in health or quality of life. The areas surveyed include: 1) Deal with Health Condition 2) Quality of Life 3) Overall Health The goal was to achieve 75% satisfaction/agreement for each topic. The target was met or exceeded. Interventions: • Upon closure of the Diabetes Program, members are encouraged to participate/provide feedback to

the survey. • Follow up outreach is done by Management to members who indicate via the satisfaction survey that

they would like to be contacted.

87% 86%80%

84%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Deal with Health Condition Overall Quality of Life Overall Health Total

Goal 75%

n = 91


Barriers and Opportunities Barrier: Clinician identification of needed testing, as recommended by the ADA Standards of Care.

Opportunity: • Collaborate with Provider Relations to educate clinicians during all site visits to improve compliance

with ADA Standards of Care recommendations.

• Collaborate with Population Health Managers to educate practices during care conferences to improve compliance with ADA Standards of Care recommendations.

Barrier: Member lack of knowledge about diabetes.

Opportunity: • Increase members’ and caregivers’ knowledge regarding the appropriate treatment, and appropriate

self-management skills for persons with diabetes.

• Increase community awareness regarding the diagnosis, appropriate treatment, and appropriate self-management skills for persons with diabetes by distributing educational materials at health fairs and events.

• Increase member awareness regarding the appropriate treatment and appropriate self-management

skills for persons with diabetes by: o Face-to-face outreach o Telephonic outreach o Member newsletters o On-hold SoundCare messages o CareMessage text messages o Passport’s website o Member educational materials

Barrier: Member lack of knowledge of ADA Standards of Care recommendations for testing and results.

Opportunity: • Educate members on the specific ADA Standards of Care recommendations for screenings/tests.

• Perform targeted telephonic outreach to diabetic members delinquent in ADA Standards of Care

recommendations for screenings/tests.

• Utilize the Care Connector Program to assist members with urgent issues related to diabetes.


Interventions completed in 2019: Provider Education: • Increased clinician awareness of the ADA Standards of Care recommended diabetic screening

including, HbA1c testing, LDL-C screening, microalbumin, DRE, BP, influenza vaccination, foot inspection, weight with BMI, and nutritional/exercise education through a Health Educator, and through Provider Relations site visits.

Member Education: • Educated members/caregivers regarding diabetic screenings through face-to-face outreach,

telephonic outreach, member newsletters, Passport’s website, and member educational material. • Continued collaboration with CareMessage vendor to provide information about preventive care to

members with Passport sponsored cell phones.

• Leveraged the Care Connector Program to engage members in need of assistance making an appointment.

• Maintained a member engagement reward strategy to encourage member compliance with

screening.

• Leveraged the use of Dietician and Social Worker for additional support to members.

• Collaborated with community partners to provide supportive services to members/families who need advance illness management services without the requirement of discontinuing active treatments.

Screening Activities: • Administered the Patient Health Questionnaire (PHQ) 2 and the Pediatric Symptom Checklist-17

(PSC-17) a depression screening used with member’s ages 4 to 17. There were 434 adult members screened and 31% of those members had a positive result, leading to the PHQ-9 being administered. Of those members, 94 were referred for Behavioral Health (BH) services. There were no pediatric members screened using the PSC-17 screening tool during 2019.

• Administered the Member Satisfaction Survey telephonically to members enrolled in the Diabetes Program, reviewed surveys as received and conducted outreach to those members who indicate “disagree” or “strongly disagree” responses on their survey. Passport monitored surveys for trends, none were identified. Provided feedback to individual staff when appropriate and addressed any identified areas that needed improvement, none identified.

Identification Activities: • Continued to improve integration and collaboration to improve overall coordination of care for members

with co-existing medical and BH diagnoses/conditions.


Community Activities: • Passport increased community initiatives related to the diagnosis and treatment of diabetes through:

o Collaborated with community partners to continue to raise awareness of diabetes within the community through local departments of health and clinics.

o Collaborated with community agencies and statewide initiatives to increase awareness of diabetes and diabetes management.

o Continued distribution of educational materials at health fairs and special events. • Participated in community forums to determine additional community resources and best practices

related to a healthy lifestyle for our members including: o School-based educational programs o Health and Wellness Fairs o Prevention Workshops

Planned Interventions for 2020: Continued Interventions: • Increase clinician awareness of the ADA Standards of Care recommended diabetic screening on

Passport’s website, through a Health Educator, and through Provider Relations site visits. • Educate members/caregivers regarding diabetic screenings through:

o Face-to-face outreach o Telephonic outreach o Member newsletters o Passport’s website o Member educational materials o Educational classes in the community

• Continue collaboration with community partners to provide supportive services to members/families

who need advance illness management services without the requirement of discontinuing active treatments.

• Continue collaboration with CareMessage vendor to provide information on preventive care to

members with Passport sponsored cell phones.

• Evaluate all new member materials to ensure each piece is clear and concise. Materials continue to be utilized for member mailings; in addition to face-to-face education with the members at the clinician’s office.

• Administer the PHQ-2, PHQ-9 (for adults) and PSC-17 (for children ages 4-17) to prescreen and screen for depression in diabetic members and refer members to the BH team as needed.

• Review surveys as received and conduct outreach to those members who indicate “disagree” or

“strongly disagree” responses on their survey.


• Monitor for trends, provide feedback to individual staff and address any identified areas that needed improvement.

• Continue to improve integration and collaboration with BH to improve overall coordination of care for

members with co-existing medical and BH diagnoses/conditions. • Continue to leverage the Care Connector Program to engage members in need of assistance making

appointment. • Continue promotion of the Member Incentive Program to encourage member compliance with diabetic

screenings/tests.

• Add outreach calls from Quality Outreach Specialist attempting to understand inappropriate use of emergency department and barriers to accessing care in more appropriate settings.

• Increase community initiatives related to the diagnosis and treatment of diabetes through: o Continue collaboration with community partners to continue to raise awareness of diabetes within

the community through local departments of health and clinics. o Continue collaboration with community agencies and statewide initiatives to increase awareness

of diabetes and diabetes management. o Continue distribution of educational materials at health fairs and special events.

Overall the Diabetes Program noted improvements in 2019, particularly in the number of members engaged in the program during the year. Based upon the 2019 evaluation, Passport developed new initiatives to strive towards the overall goal of improving the health and quality of life for our members with diabetes.

2019 Diabetes Program Evaluation...• During the measurement year, increase clinician adherence to...

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