Blue Care Network Best Practices

Diabetes care

Fowlerville Medical Center focuses on diabetic patients

Cecilia Ebert discusses a patient with Dr. Norine Tracy.

Treating diabetic patients can be challenging for practices because there are several important recommended tests for diabetics, some that require the patient to go to an outside laboratory or optometrist for screening.

Blue Care Network tracks providers who treat diabetics against the Healthcare Effectiveness Data and Information Set® measurements to evaluate our health plan. Fowlerville Medical Center attributes its high success rate in completing the tests for their diabetic patients to their careful tracking system, a new patient database and comprehensive patient education.

Fowlerville Medical Center has one physician, Norine Tracy, M.D., one nurse practitioner, one R.N. and two L.P.N.s on staff. Cecilia Ebert, R.N., is the office manager and is mainly responsible for reviewing charts and making sure the diabetic patients get the recommended testing. The practice has 278 diabetic patients out of about 4,000 active patients.

"One of the things that has helped us keep track of our patients is the Wellcentive database that we use through our physician organization," explains Ebert. "The system captures our patients by diagnosis and makes it easy for me to pull up our diabetic patients to see when they are due for specific tests. The database is only a few months old, but we can see how it will eventually be easy to identify every diabetic patient we have."

Until now, much of the tracking has been done manually. Testing results are still tracked manually. "We keep a copy of the order if they get a lab order," says Ebert. "If the results don't return to us within a month, we send a reminder letter to the patient."

One of the challenges with testing diabetic patients is that most of the testing is done at an outside laboratory. Only the urine microalbumin is done in the office, says Ebert.

Eye exams are sometimes difficult to track because patients go to an optometrist or ophthalmologist for their exams. "If we order an eye exam, it goes into a log. If the test result is not back in a month, we call the patient or the eye doctor's office to see why we didn't get a report," explains Ebert. "We also see uninsured patients who may go to Walmart for their eye exams, so sometimes we have to ask them to go back because the diabetic test wasn't completed."

The office tracks all HEDIS testing for Blue Care Network by entering the results into the Heath e-BlueSM system.

Patient education boosts compliance

Educating diabetics about the need for tests helps increase compliance. Fowlerville Medical Center has a room dedicated to diabetes education. Dr. Tracy developed a form that includes all the required tests, the frequency and when they need to be completed. This helps diabetic patients understand all the required screenings.

Ebert works with new diabetic patients to help them digest all the information they need when they are first diagnosed. The office also conducts group education sessions with between six and 10 patients. Some seminars are conducted by diabetes educators from pharmaceutical companies. "We may also do an individual session for a patient who is noncompliant," Ebert says.

Ebert says the diabetes education offered at St. Joe's Livingston is a great resource for the practice. "Their diabetes educators start with seminars on diet and go through a whole series of lectures," explains Ebert. The practice sends patients to St. Joe's, sometimes recommending specific sessions, particularly if the patient needs further education about diet. "Four times a year, we send out invitations to patients," says Ebert.

Ebert also makes reminder calls. "I know our patients well enough so I know who needs to come in for education," she adds.

Ebert says that initially the practice focused on Blue Care Network patients. "Now that we have better ways of identifying patients and capturing information, we focus on everyone."

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