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Chronic Disease Management

Diabetes Care

Guideline Information

Guideline title: Diabetes Care Report and Guidelines

Publication Status: Active

Date of publication: January 2024

Date of last evidence search: 2023

Scope: Team-based care and empanelment (ambulatory care, inpatient care, dental, health plans), population health, and minimizing financial burden and standardizing coverage.

Methods: Current guidelines and literature review and expert consensus

Description: Diabetes was selected by Bree Collaborative members in September 2022 and a workgroup of clinical and community experts met from January 2023 to January 2024. Key priorities to improve population health and equity are: Increase performance on NCQA measures for people who have been diagnosed with diabetes; Identify individuals with pre-diabetes or diabetes who are unaware of their status and engage them in treatment and prevention; Uniformly use team-based care to support individuals with diabetes or at risk for diabetes; Promote connection to community resources, address social needs, access to prevention and health promotion activities; Support patients’ medication and supplies use by removing payment barrier.

Implementation Checklists by Audience

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Ambulatory Care Setting

Level 1

Level 2

Level 3

Health Care Professional Checklists

Level 1A (all patients and people with pre-diabetes)

Level 1B (people with diabetes)

Level 2

Note: No level 3 for this audience

Metrics and Evaluation Tools

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Ambulatory Care

Ambulatory Care Evaluation Score Card Ambulatory Care_Score Card_Final

Note: Metric 1-3 are not endorsed and should be tested prior to implementation.

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Metric 4 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 5 – Kidney Health Evaluation for Patients with Diabetes (KED) (HEDIS), by race, ethnicity/language, insurance status

Metric 6 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Metric 7 – Hemoglobin A1c Control for Patients with Diabetes (HBD) (HEDIS) NQF# 0059, by race, ethnicity/language, select comorbities, insurance status

Metric 8 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Hospitals

Hospital Evaluation Score Card Hospitals_Score Card_Final

Dentists

Dentist Evaluation Score Card Dentists_Score Card_Final

Metric 1 – Percent of patients who have been screened for a primary car provider visit in the last 6 months

Dental Plans

Dental Plan Evaluation Score Card Dental plans_Score Cards_Final

Metric 1: Percent of members who have been screened for a primary care provider visit in the last six months

Schools

School Evaluation Score Card School_ Score Card _Final

Health Plans

Health Plan Evaluation Score Card Health-Plan_Score-Card_Final

Recommended metrics for all patients and for inclusion into contracts:

  • Social Needs Screening and Intervention (SNS-E)
  • Adult Immunization Status (AIS)

Recommended metrics for prediabetes patients:

  • Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.
  • Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.
  • Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Recommended metrics for patients with diabetes and for inclusion into contracts:

  • Hemoglobin A1c Control for Patients with Diabetes (HBD)
  • Blood Pressure Control for Patients with Diabetes (BPD)
  • Eye exam for patients with diabetes (EED)
  • Kidney Health Exam for Patients with Diabetes (KED)
  • Statin Therapy for Patients with Diabetes (SPD)

Washington State Health Care Authority

Washington State Health Care Authority Evaluation Score Card Health Care Authority_Score Card_Final

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period

Metric 4 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Metric 5 – Adult Immunization Status (AIS-E)

Metric 6 – Kidney Health Evaluation for Patients With Diabetes (KED)

Metric 7 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 8 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Employers and Health Care Purchasers

Employers and Health Care Purchasers Evaluation Score Card Plans_Purchasers_Score Card_Final

Health care purchasers should consider including or requiring tracking of all recommended metrics on the Washington State Health Care Authority tab in this section.

Employers should consider developing measures for and tracking the following:

  • Days of work missed due to complications from Diabetes
  • Number of employees receiving evidence-based care for diabetes
  • Number of employees with diabetes who have same day access to care
  • Rapid return to function after diabetes complications
  • Patient experiences with diabetes care
  • Total cost of care for patients with diabetes

Workgroup Members

Name Title Organization
Norris Kamo, MD, MPP (chair) Section Head, Adult Primary Care Virginia Mason Franciscan Health
Susan Buell Associate Director of Health Initiatives YMCA of Pierce County
LuAnn Chen, MD, MHA Medical Director Community Health Plan of Washington
Sharon Eloranta, MD Medical Director, Performance Measurement and Practice Washington Health Alliance
Rick Hourigan, MD Market Medical Executive Cigna
Carissa Kemp, MPP State Government Affairs and Advocacy Director American Diabetes Association
Vickie Kolios, MSHSA, CHPQ Program Director, Surgical and Spine COAP Foundation for Health Care Quality
Robert Mecklenberg, MD Medical Director (retired) Virginia Mason Medical Center
Mamatha Palanati, MD Family Medicine Physician Kaiser Permanente
Khimberly Schoenacker, RND, CSP, CD CYSHCN Program Washington Department of Health
Cyndi Stilson, RN, BSN, CMM Care Management Manager Community Health Plan of Washington
Sally Sundar Program Executive, Health Integration and Transformation The Y of Greater Seattle
Nicole Treanor, MS, RD, CD, CDCES Diabetes Care and Education Specialist (DCES) Virginia Mason Franciscan Health
Sheryl Morelli, MD, MS Chief Medical Officer Seattle Children’s Care Network
Leah Wainman Equity and Health Assessment Manager Washington Department of Health

Pediatric Asthma

Guideline Information

Guideline title: Pediatric Asthma Report and Guidelines

Publication Status: Active

Date of publication: January 2023

Date of last evidence search: 2022

Scope: Asthma management across settings (school, clinical, home, etc.),  care coordination, exposure reduction, funding

Methods: Current guidelines and literature review and expert consensus

Description: Given the multidisciplinary nature of pediatric asthma control, this guideline focuses on strategies to align efforts across key stakeholders. Guidelines are meant to supplement existing treatment guidelines from the National Asthma Education and Prevention Program, best practices for community interventions from the CDC’s Community Preventative Services Task Force, and expectations for pediatric asthma care in schools from Washington State’s Asthma Management in Educational Settings guide. Additionally, this guideline builds off previous work to mitigate the effects of climate on asthma from the Asthma and Allergy Foundation of America and offers strategies for funding pediatric asthma interventions drawing from previous research on funding mechanisms from the Brookings Center for Health Policy.

Implementation Checklists by Audience

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists

 Level 1

Level 2

Level 3

Health Care Professional Checklists

Level 1

Level 2

Level 3

Public Health Agency Checklists

Level 1

Level 2

Level 3

Organizations Working with Community Health Worker Checklists

Level 1

Level 2

Level 3

Metrics and Evaluation Tools

Delivery Site and Health Systems

Health System Evaluation Score Card Health System Score Card _ Ped Asthma2

Home Services Evaluation Score Card Home services score card _ Ped Asthma

School Services Evaluation Score Card School services score card _ Ped Asthma – C

Health Care Professionals (in development)

Health Plans

Health Plan Evaluation Score Card Health Plan Score Card _ Pediatric asthma

Purchasers and Employers

Purchasers/Employers Evaluation Score Card Purchaser payer Score Card _ Ped Asthma

Schools

School Score cards School services score card _ Ped Asthma – C

Guideline Metrics

The Pediatric Asthma work group’s focus was on cross-sector alignment to reduce the burden of Asthma in Washington. The group did not identify specific measures, however some standard metrics may be relevant to this work or are include in VBP contracts or HCA certification standards.

  • Asthma Medication Ratio (AMR)
    • The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
  • Child and Adolescent Well-Care Visits (WCV)
    • The percentage of members 3–21 years of age who had at least one comprehensive well- care visit with a PCP or an OB/GYN practitioner during the measurement year.
  • Potentially Avoidable Use of the Emergency Room
    • The percentage of total ER visits considered potentially avoidable based on an agreed- upon list of ICD codes. This is considered a conservative measure of potentially avoidable ER use.

Workgroup Members

Name Title Organization
Annie Hetzel, MSN, RN School Health Services Consultant Office of the Superintendent of Public Instruction
Brad Kramer, MPA Asthma and Community Health Worker Program Manager Public Health, Seattle & King County
Christopher Chen, MD Associate Medical Director Washington State Health Care Authority
David Ricker, MD Pediatric Pulmonologist/Sleep Specialist Mary Bridge Children’s
Doreen Kiss, MD Physician University of Washington
Edith Shreckengast, MS Clinical Health Coach – Registered Dietitian Community Health Plan of Washington
Julee Christianson Directory, Health Schools Program Office of the Superintendent of Public Instruction
Kate Hastings Senior Policy Expert Scientific Consulting Group
Brad Kramer, MPA Asthma and Community Health Worker Program Manager Public Health, Seattle & King County
Katie Paul, MD, MPH Physician Kaiser Permanente
LuAnn Chen, MD, MHA Senior Medical Director Community Health Plan of Washington
Mark LaShell, MD Allergist-Immunologist Kaiser Permanente
Michael Dudas, MD Pediatrician Virginia Mason Medical Center
Sheryl Morelli, MD, MS Chief Medical Officer Seattle Children’s Care Network
Vicki Kolios, MSHSA, CPHQ Senior Program Director, Spine and Surgical COAP Foundation for Health Care Quality
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