NUR 653 Module 3 Milestone One Example

Milestone One: A Population Assessment of Adults With Diabetes in an Accountable Care Organization

[Student Name]

Southern New Hampshire University

NUR 653: Population Care Management

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: A Population Assessment of Adults With Diabetes in an Accountable Care Organization

A program to improve diabetes care should begin with an accurate picture of the whole population with diabetes, not just the patients who visit most often. Mesa Valley, the composite ACO whose eleven practices serve 42,000 attributed patients, has a shared savings contract that rewards improvements in diabetes control. Before choosing interventions, the population care manager was asked to assess the organization's diabetes population. This milestone describes how the registry was built, reports performance on key measures, examines differences by practice and patient group and rates the practices' readiness using the chronic care model. It argues that a population assessment that measures everyone, compares results with standards and national data, looks for disparities and examines practice systems will point to the priorities most likely to improve outcomes.

Building the Registry

The registry includes attributed adults aged 18 to 75 with diabetes identified by any of three criteria in the past two years: two outpatient diagnosis codes, one inpatient diagnosis code or an active prescription for a glucose-lowering medication other than metformin alone, since metformin is also prescribed for prediabetes. This definition identified 3,860 patients, 9.2% of the attributed adult population. To check accuracy, nurses reviewed 200 randomly selected charts; 193 patients clearly had diabetes, and the seven errors were mostly patients with prediabetes coded incorrectly. A separate search of laboratory results found 112 patients with two A1c values of 6.5% or higher but no diabetes diagnosis, who were added to a list for clinician review.

Performance Against Standards

The 2024 ADA Standards of Care recommend an A1c goal of less than 7% for many nonpregnant adults when it can be achieved without significant hypoglycemia, with less stringent goals, such as less than 8%, for patients with limited life expectancy or high risk of hypoglycemia (American Diabetes Association Professional Practice Committee, 2024). Because individual goals vary, the assessment used common population measures. In the past twelve months, 71% of registry patients had an A1c test. Among those tested, 62% had an A1c below 8%, and 18% had an A1c above 9%, the level usually treated as poor control. Adding untested patients to the poor control group, as quality programs typically do, raises that figure to 42%. Blood pressure below 140/90 was documented for 64%, 68% of patients aged 40 to 75 had a statin prescription, 44% had a retinal exam and 38% had a urine albumin test for kidney disease. A quarter of registry patients had no primary care visit in the past year.

These results resemble national patterns. Ali et al. (2013), analyzing national survey data through 2010, found improvements over the previous decade but reported that only about half of adults with diabetes met individual targets for glucose, blood pressure and cholesterol, and fewer than one in five met all three. Mesa Valley's weakest measures, kidney screening and retinal exams, and its large group of untested patients represent the most room for improvement.

Differences by Practice and Patient Group

Results varied widely across practices. The proportion of tested patients with an A1c above 9% ranged from 11% in the best-performing practice to 29% in the worst, and the proportion with no visit in a year ranged from 14% to 37%. The two practices with the poorest results serve mostly rural patients and have the highest turnover of medical assistants. Differences by patient group were also marked. Among patients whose preferred language is Spanish, 27% of tested patients sat above an A1c of 9%, compared with 16% of English-speaking patients. Among patients enrolled in Medicaid, 26% had an A1c above 9% and 34% had no visit in a year. These differences suggest that improvement efforts must be designed to reach specific groups and practices, not applied uniformly.

Practice Systems and the Chronic Care Model

Outcomes depend on how practices are organized. Bonomi et al. (2002) developed the Assessment of Chronic Illness Care, a practical instrument in which practice teams rate their systems on each element of the chronic care model, including organization of the delivery system, community linkages, self-management support, decision support, delivery system design and clinical information systems, and they found it responsive to quality improvement efforts. Each practice team completed the assessment together. Scores were highest for decision support, since all practices use the same diabetes guideline, and lowest for self-management support and community linkages. Only three practices reported using a registry for proactive outreach before this assessment, and none had a structured diabetes self-management education program on site. The two lowest-performing practices also rated their clinical information systems lowest.

Priorities

The assessment points to four priorities. First, re-engage the 24% of patients with no visit in a year, beginning with the two practices where the gap is largest. Second, close process gaps in kidney screening, retinal exams and statin prescribing through standing orders and registry-driven outreach. Third, improve glucose control for patients with an A1c above 9%, with particular attention to Spanish-speaking patients and Medicaid enrollees, through culturally and linguistically appropriate self-management support. Fourth, strengthen practice systems, especially registry use, self-management support and community linkages, in the lowest-scoring practices. These priorities will guide the program designed in Milestone Two.

Limitations

Claims and electronic record data can miss care delivered outside the organization, such as eye exams at independent optometrists, so some process measures may be understated. Preferred language was missing for 8% of patients. The chronic care model ratings are self-reported and may be optimistic. These limitations will be addressed by importing external eye exam reports, improving language data collection and repeating the assessment annually.

Conclusion

Mesa Valley's diabetes population is larger and less well served than visit-based reports suggested. A validated registry shows that a quarter of patients have not been seen in a year, that kidney and eye screening lag, that poor control is concentrated among Spanish-speaking and Medicaid patients and in two rural practices and that practice systems for self-management and community links are weak. These findings define where the program should begin.

References

Ali, M. K., Bullard, K. M., Saaddine, J. B., Cowie, C. C., Imperatore, G., & Gregg, E. W. (2013). Achievement of goals in U.S. diabetes care, 1999-2010. New England Journal of Medicine, 368(17), 1613-1624. https://doi.org/10.1056/NEJMsa1213829

American Diabetes Association Professional Practice Committee. (2024). 6. Glycemic goals and hypoglycemia: Standards of care in diabetes 2024. Diabetes Care, 47(Suppl. 1), S111-S125. https://doi.org/10.2337/dc24-S006

Bonomi, A. E., Wagner, E. H., Glasgow, R. E., & VonKorff, M. (2002). Assessment of chronic illness care (ACIC): A practical tool to measure quality improvement. Health Services Research, 37(3), 791-820. https://doi.org/10.1111/1475-6773.00049