Successful Approach to Comprehensive Diabetes Care in Challenging Populations

In traditional clinical practice, the opportunity to validate the best practices among a large sample of patients is minimal for healthcare professionals.

However, the recently launched Centers for Medicare and Medicaid (CMS) Medical Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs), offers providers incentives for improved quality of care and lowered costs associated with healthcare and demands that ACOs monitor and publicly disclose the results they have collected, allowing ACOs to analyze the data.

A novel, multi-year, comprehensive care plan has been implemented by a Texas-based ACO covering thousands of type 2 diabetes mellitus (T2DM) patients. As part of the plan, in-office point-of-care (POC) testing is provided to the patients.

The ACO recently presented the program results at the 2016 American Diabetes Association annual meeting held in New Orleans. From the results, the care plan was shown to be effective in improving patients’ outcomes with a considerable reduction in healthcare costs, providing a blueprint that can be reproduced on a much larger scale to address the growing economic and epidemiological effect of T2DM in the US.

RGV’s T2DM care program

One of over 500 ACOs across the United States, the Southern Texas based Rio Grande Valley (RGV) ACO was formed as part of the Affordable Care Act’s Medicare Shared Savings Program to minimize unnecessary costs for Medicare Fee-For-Service beneficiaries with an improved quality of care.

Despite the challenging demographic, the RGV ACO was able to achieve significant savings with quality scores that are one of the best in the country. The RGV ACO team has made diabetes control the area of focus, and designed a set of breakthrough strategies for better management of this devastating condition affecting roughly 45% of its patient population.

Most of the ACO’s patients lack health literacy and are not aware of the role a healthy diet and other lifestyle inteventions can play in stabilizing their T2DM. In addition, many of them cannot afford for their T2DM medication copayments or do not have the money to buy nutrient-rich foods or go to the gym to support healthy eating patterns or lifestyles.

RGV’s T2DM care program consists of many different strategies. The team at the RGV ACO follows up patient visits through phone calls, reminding the patients about blood glucose monitoring or making medication adjustments.

Certified diabetes educators and nutritionists handle uncontrolled patients. RGV’s electronic health records platform alerts the staff about care gaps. Point-of-care systems are used by the RGV ACO to measure lipids and HbA1c in office so that clinicians can immediately take necessary action on the test results.

Obtaining lipid and HbA1c results during a patient visit allows the staff to fully utilize each visit without the need to spend additional time later on to get charts for review and follow up with patients following the receipt of lab results in the subsequent days.

Less time is required for chasing patients and results with letters and phone calls. POC testing for lipids and HbA1c not only increases office efficiency, but also provides a number of other benefits including:

  • Additional visits can be avoided for laboratory tests and follow-up
  • Additional patient compliance owing to improved understanding
  • Better delivery of care, training, and education

Until today, the number of patients enrolled on this innovative care plan is more than 6000. Significant improvements have been achieved in all quality measures, including blood pressure, HbA1c levels, and tobacco non‐use.

Between 2012 and 2014, the number of patients with HbA1c >9% was decreased from 17.81% to 12.83%, whereas the number of patients with comprehensive T2DM control was increased from 12% to 49%.

For the composite score of T2DM metrics, the RGV ACO reached the top 1% of all ACOs in the country. Moreover, a 14% reduction in the per capita costs was achieved by the RGV ACO for its Medicare beneficiaries.

The results of our program are especially gratifying because they show that T2DM can be successfully and cost-effectively managed among patients who are traditionally difficult – and expensive – to treat. We now know definitively that there is no ‘silver bullet’ when it comes to managing T2DM. Healthcare providers need to use a wide range of interventions and strategies, including rapid point-of-care testing, frequent phone calls by care coordinators and others that are culturally tailored to their patients.”

Jose F. Pena, MD, Chief Executive Officer and Chief Medical Director, RGV ACO.


The RGV ACO case study reveals that a successful approach can be designed for providing comprehensive diabetes care among challenging populations with a better quality of care and a significant reduction in healthcare spending.

The aim is to bring increased efficiency in health care delivery and improved diabetes control, so that diabetic patients of all ages as well as providers and payers can benefit significantly.


Produced from materials originally authored by Gillian Parker, Senior Director, Diabetes, Cardiometabolic Business Unit, Alere Inc.

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Last updated: Mar 20, 2017 at 6:12 AM


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