} CHSI is working to identify the percentage of patients that are diagnosed with pre-diabetes.

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2 } CHSI is working to identify the percentage of patients that are diagnosed with pre-diabetes. } Get all providers within the clinic to include the diagnosis in the problem list } Implement an evidenced based program such as the National Diabetes Prevention Program to prevent progression to Type II diabetes. } Patient awareness FACTS: Nationally, 1/3 of all adults fall into the A1C lab range 9 out of 10 patients aren t aware of their prediabetes status.

3 } An opportunity to identify those being missed } Healthier patients } Improve patient outcomes } Education for staff } Improved UDS diabetes measure } Money } Satisfaction } Improve our clinic practice

4 } Approached by the MN Department of health } Time frame Sept 2017-Sept 2018 } Monthly meetings Administration, clinical staff, PartnerSHIP 4 Health coordinator, Program Manager/Healthcare IT Consultant from Stratis Health, CHSI HIT } Started with the Moorhead clinic and expanded from there

5 } We developed an action plan } Built some SMART goals } Decided who was going to be part of the team } Set monthly meeting dates } Identified those with an A1C in the prediabetes range } Identified those with an A1C in the prediabetes range with a documented diagnosis of prediabetes } Trainings -Motivational interviewing and DPP } Reviewed evidenced based guidelines and best practices } Discussed a screening protocol } Standing orders } Standardized the predm DX

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7 } By June 1, 2018, increase the % of adult patients in CHSI Clinics with an A1C in the prediabetes range ( ) who have a documented diagnosis of prediabetes from 13.6% to 25%. } } By June 1, 2018, increase the % of adult patients in the Moorhead CHSI Clinic with an A1C in the prediabetes range ( ) who have a documented diagnosis of prediabetes from 40.0% to 80%.

8 Timeframe: January 1, 2016 December 31, 2016 Clinic Site # patients with A1C between % # with a prediabetes Dx % # with a Type II borderline Dx Moorhead % 1 Grafton % 6 Rochester % 9 Wilmar % 20 Total: 132 Total: 18 Avg: 13.6% Timeframe: January 1, 2017 September 20, 2017 Clinic Site # patients with A1C between % # with a prediabetes Dx % # with a Type II borderline Dx Moorhead % 2 Grafton %? Rochester %? Wilmar % 22

9 } Healthcare Homes Learning collaboration } Motivational Interviewing } Diabetes Prevention network } Statewide collaboration calls } Lifestyle coach training } Diabetes Prevention Program (Prevent T2) CDC approved curriculum estyle-program/curriculum.html

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12 } Receive letter to register for DPP Your Provider has Identified you as a candidate for the Diabetes Prevention Program. This means you have certain risk factors that put you at greater risk of developing Diabetes in the coming years. Such as: our age, elevated BMI, history of fasting blood sugar at , A1C 5.7%-6.4%, history of gestational Diabetes, or plasma GTT Before people develop Diabetes they usually have prediabetes. That means your blood sugar levels are higher than normal, but not yet high enough to be called Diabetes. People with pre-diabetes are more likely to develop Diabetes in 10 years and are more likely to have a heart attack or stroke.. } Refer to provider

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15 Pre-Diabetes Screening and Treatment Protocol } Patient should receive a Pre-DM Risk Test at the Registration Desk Criteria for inclusion: Patient is 18 years of age and older Patient is new to the clinic or has not been seen in >1yr Screening is requested by RN or Provider. } RN calculates the patient s BMI and reviews the Risk Test results with the patient on the arrival to the exam room and discusses pre-diabetes risk If score is <5 No screening is indicated If score is >5---RN can proceed with ordering point of care Hemoglobin A1C testing per this standing protocol. No provider approval necessary } RN only visit: RN should document Pre-DM risk score and POC A1C score in the EMR } Provider visit: If POC A1C is <5.7, RN should set goals with the patient concerning diabetes prevention using motivational interviewing skills, and document the goals in the EMR If the POC A1C is > , RN should make patient aware of likelihood of pre-diabetes, set goals with the patient utilizing MI skills, and schedule the patient for follow-up with the provider within 2 weeks and repeat POC or serum A1C testing at follow-up If the POC A1C is >6.5, RN should make patient aware of likelihood of diabetes, set goals with the patient utilizing MI skills, and schedule the patient for follow-up with the provider within 2 weeks and repeat POC or serum A1C testing at follow-up RN should document Pre-DM risk score and POC A1C score in the EMR and discuss goals determined by the patient with the provider If POC A1C is <5.7, counsel patient on methods of preventing diabetes, and set goals If POC A1C is , provider can consider confirmation with a serum A1C, or can proceed with diagnosing pre-diabetes and enter ICD-10 code for pre-diabetes (R73.09) in the patient s chart If the POC A1C is >6.5, provider should confirm with serum A1C at a later date and patient should be diagnosed with DM For patients diagnosed with pre-dm Give educational handouts and counsel on diabetes prevention. Evaluate and control other risk factors for heart disease Refer to diabetes prevention program, or set patient up with individual counseling with RN for diabetes prevention (if available). Consider metformin especially if age <60, BMI>35, or hx of prior gestational DM Start Metformin at 500mg BID and after two weeks increase to 1000mg BID as tolerated Contraindications: Liver failure, dialysis, Cr >1.4 in males and 1.4 in females Frequency of re-screening: If A1C >6, repeat every 6 months If A1C< or equal to 6, repeat every 12 months. Note: If patient confirms that they already have a diagnosis of pre-diabetes, there is no need for re-screening. } Ensure adequate and regular follow-up of these patients. Troubleshoot issues with enrollment in diabetes prevention programs or medication concerns.

16 } Started with the MHD clinic } Expanded to Willmar and Grafton } Rochester clinic Pending implementation } Trained supervisors } Relied on Supervisors to teach their clinic about our program, goals, work plan ect. } Carlene presented during a provider meeting on expectations from providers } Quarterly reports } Share Data } Data presented to QI committee

17 } Social Media FB & Twitter #prediabetes often has no symptoms, but it's important to know where you stand. Visit DoIHavePrediabetes.org to find out if you're at risk. Learning if you have #prediabetes is the first step to a healthier future. Take the risk test at DoIHavePreDiabetes.org and learn how to prevent type 2 diabetes.

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19 } Pulling data questioning accuracy } Diagnosis } Smart quick text } Group visits Vs Individual } DPP 12 month program } DPP Interpreters } Reimbursement & Coding } Talking with patients about their predm DX and the need for lifestyle changes } Documentation } Turn over

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