Care management efforts focused on patients not achieving quality goals can improve performance in value-based care quality programs, but may pose challenges for integration into routine clinical care. We evaluated a 12-month NP-led care management pilot program (CMPP) to improve outcomes for adults with T2DM and A1c>9% (N=62, 40% male) covered under a value-based care quality program and receiving care at a diabetes center. Visits were scheduled as billable encounters between routine clinical visits. Diabetes quality outcomes (A1c≤9%, BP<140/90, and annual retinal screening) were assessed by CMPP participation. For this pilot program, p<0.05 and p<0.10 defined significance and trend, respectively. The CMPP began in November 2020 with 43% (n=27) participation; participants and non-participants had no baseline differences in age, diabetes duration, or baseline attainment of diabetes quality metrics. CMPP participants had more visits compared to non-participants over the 12 month pilot period (10.4 vs. 4.0, p<.001); 62% of participant visits were virtual vs 47% among non-participants (p=.01). At 12 months, CMPP participants had a significant improvement in % A1c≤9% and trended towards improved annual retinal screening. This integrated NP-led CMPP leveraging virtual care may improve diabetes quality outcomes. Future efforts will focus on scaling and implementation in primary care.
L.J.Tinsley: None. K.D.Ariyabuddhiphongs: None. E.Halprin: None. J.Beaulieu: None. M.Moreau: None. A.Millan-ferro: None. J.Rizzotto: None. B.Cronin: None. S.N.Mehta: None.
