PREVENTING TYPE 2 DIABETES. A guide to refer your patients with prediabetes to an evidence-based diabetes prevention program

Transcription

1 PREVENTING TYPE 2 DIABETES A guide t refer yur patients with prediabetes t an evidence-based diabetes preventin prgram

2 Preventing diabetes: Making a difference by linking the clinic with the cmmunity. In the average primary care practice, it s likely that ne-third f patients ver age 18, and half ver age 65, have prediabetes. Use this guide t help yur patients delay r prevent the nset f type 2 diabetes Prediabetes is a health cnditin characterized by bld glucse levels that are higher than nrmal, but nt high enugh t be diagnsed as diabetes. Prediabetes increases the risk fr type 2 diabetes, heart disease and strke. Prediabetes is treatable, but nly abut 10 percent f peple wh have it are aware that they d. Left untreated up t ne-third f peple with prediabetes will prgress t diabetes within five years. During that windw f time yur patients can benefit frm a prven lifestyle change interventin that is part f the Natinal Diabetes Preventin Prgram (Natinal DPP) led by the Centers fr Disease Cntrl and Preventin (CDC). As part f the Natinal DPP, the American Medical Assciatin (AMA) and the CDC are cllabrating t create tls and resurces that care teams can use t identify patients with prediabetes, and refer eligible patients t in-persn r nline diabetes preventin prgrams. Physicians and care teams frm a diverse grup f practices helped the AMA and the CDC create the tls in this guide, and have used them in their wn practices t: Screen and identify patients fr prediabetes Refer patients t diabetes preventin prgrams Create feedback lps, linking the patient s prgress in the diabetes preventin prgram back t the practice Part f a natinal mvement T achieve CDC recgnitin as part f the Natinal DPP, prgrams must prvide evidence they are fllwing a CDC-apprved curriculum and achieving meaningful results with patients. These prgrams are based n research shwing that a year-lng, structured lifestyle change interventin reduced the incidence f diabetes by 58 percent amng adults with prediabetes and by 71 percent in thse aged 60 years r lder. These prgrams are successful in part because they require nly mderate weight lss t achieve preventive health benefits. Weight lss f 5 t 7 percent f bdy weight t 14 punds fr a persn weighing 200 punds-----led t the results mentined abve. The AMA and the CDC are prmting these diabetes preventin prgrams because they are ne f the mst effective ways t help physicians prevent r delay type 2 diabetes in high-risk patients. Use this implementatin guide and its tls t help identify and refer patients with prediabetes t a diabetes preventin prgram that is part f the CDC s Natinal DPP. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

3 Overview f guide tls Resurce Engage clinicians Yu can prevent type 2 diabetes Health care prvider fact sheet Engage patients Diabetes Risk Assessments CDC and American Diabetes Assciatin (ADA) questinnaires Prmting prediabetes awareness t yur patients 8" x 11" pster) Are yu at risk fr type 2 diabetes? Patient handut S yu have prediabetes nw what? Patient handut Sample Patient letter/ and phne script Purpse Incrprate screening, testing and referral int practice M.A.P. t diabetes preventin fr yur practice One-page verview Patient flw prcess Infgraphic Pint-f-care prediabetes identificatin algrithm Infgraphic and narrative Retrspective prediabetes identificatin algrithm Infgraphic and narrative Sample patient referral frm/table fr calculating bdy mass index Cmmnly used CPT and ICD cdes Table Cnnect yur clinic with diabetes preventin prgrams Link t sample Business Assciate Agreement n AMA's website Prvides a brief verview f the evidence-based diabetes preventin prgram and a ratinale fr engaging with the prgram, such as imprved patient utcmes. Als assists clinicians in advcating t their clleagues and leaders abut the value f incrprating diabetes preventin screening and referral int their practices. Offers an educatinal pprtunity fr patients t learn abut their risk fr prediabetes, and help physicians and care teams identify their patients at great risk. Helps practices increase patient awareness f prediabetes t pave the way fr cnversatins with patients abut screening and referral. Fr use by physician practices in patient waiting areas t increase patient awareness and pave the way fr cnversatins with patients abut screening and referral. Fr use by physician practices in the exam rm after screening has revealed that a patient has prediabetes. Helps the patient leave the ffice visit with cncrete infrmatin fr later reference. Enables physician practices t cnduct efficient fllw-up and referral with patients wh have been identified as having prediabetes, infrming them f their prediabetes status and referral t an evidence-based diabetes preventin prgram. Offers practices a ne-page radmap t applying the elements f the diabetes preventin screening and referral guide. Prvides a high-level verview f hw ffice staff can facilitate pint-f-care identificatin. With a graphic n ne side, and narrative n ther, the dcument ffers practices an ptin t adapt/ incrprate a prediabetes screening and referral prcess int their wrkflw. With a graphic n ne side, and narrative n ther, the dcument ffers practices an ptin t adapt/ incrprate an identificatin and referral prcess int their electrnic health recrds and generate a registry f patients at risk fr type 2 diabetes. Makes the referral prcess easier fr practices, helps engage the patient (particularly if they sign the ptinal patient signature bx) and prepares diabetes preventin prgram prviders t engage with the patient as well. Enables physician practices t btain reimbursement fr prediabetes screening. Prvides link t template agreement sme practices have used t share infrmatin with diabetes preventin prgram prviders. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

4 Additinal infrmatin AMA diabetes preventin initiative preventdiabetesstat.rg Learn mre abut the AMA s cmmitment t preventing type 2 diabetes. Centers fr Disease Cntrl and Preventin s Natinal Diabetes Preventin Prgram cdc.gv/diabetes/preventin Visit this site fr detailed infrmatin abut the CDC s Natinal Diabetes Preventin Prgram. Natinal Diabetes Educatin Prgram ndep.nih.gv/am-i-at-risk/ Find educatinal resurces abut preventing diabetes fr yu and yur patients. Hw des a diabetes preventin prgram wrk? Diabetes preventin prgrams that are part f the Natinal DPP use lifestyle change interventins that target imprving diet, increasing physical activity and achieving mderate weight lss. The gal fr each participant is t lse 5% f bdy weight by: Prgressively reducing dietary intake f calries and fat thrugh imprved fd chices Gradually increasing mderate physical activity (e.g., brisk walking) t 150 minutes per week Develping behaviral prblem-slving and cping skills Features include: A year-lng structured prgram (in-persn grup, nline r distance learning) cnsisting f: -- An initial six-mnth phase ffering at least 16 sessins ver weeks -- A secnd six-mnth phase ffering at least ne sessin a mnth (at least six sessins) Facilitatin by a trained lifestyle cach Use f a CDC-apprved curriculum Regular pprtunities fr direct interactin between the lifestyle cach and participants An emphasis n behavir mdificatin, managing stress and peer supprt Wh is eligible fr referral t a diabetes preventin prgram? T be eligible fr referral, patients must: Be at least 18 years ld and Be verweight (Bdy Mass Index (BMI) 24*; 22 if Asian) and Have a bld test result in the prediabetes range within the past year: -- Hemglbin A1C: % r -- Fasting plasma glucse: mg/dl r -- Tw-hur plasma glucse (after a 75 gm glucse lad): mg/dl r Be previusly diagnsed with gestatinal diabetes and Have n previus diagnsis f diabetes Physicians and ther health care prviders shuld als use their independent judgment when referring t a diabetes preventin prgram. *Sme diabetes preventin prgram prviders require a BMI f 25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

5 Hw can patients find a diabetes preventin prgram near them? Diabetes preventin prgrams are available in varied lcatins such as lcal YMCAs, wellness centers, faith-based rganizatins and wrksites-----as well as in health care facilities. Online versins are als available. Visit cdc.gv/diabetes/ preventin/recgnitin/registry.htm#prgram t find a prgram that is part f the CDC s Natinal DPP recgnitin prgram. Des health insurance cver patient participatin in a diabetes preventin prgram? A grwing number f private health insurers ffer cverage fr patient participatin in diabetes preventin prgrams. Several emplyers include cverage as part f wrkplace wellness prgrams. Csts fr a full year f prgram participatin are apprximately $400-- $500. Sme prgram prviders ffer mnthly payment plans and discunts based n ability t pay. The AMA and the CDC cntinue t advcate fr public and private insurance cverage f the diabetes preventin prgram. Hw d I cde fr prediabetes screening? Depending n the type f ffice visit, practices can use several CPT and ICD cdes t bill fr prediabetes screening and cunseling. A list f cmmnly used CPT and ICD cdes is included in this guide. Feedback frm diabetes preventin prgram t referring clinicians Mst prgrams send reprts f participant prgress t referring clinicians after the eighth and 16th grup sessins. In additin, participants in the prgram cmplete peridic self-evaluatins that referring clinicians can request directly frm patients. Sending patient infrmatin t a diabetes preventin prgram prvider Business Assciate Agreement Under the U.S. Health Insurance Prtability and Accuntability Act f 1996 (HIPAA), a HIPAA Business Assciate Agreement (BAA) is a cntract that prtects persnal health infrmatin in accrdance with HIPAA guidelines. Sme physician practices may want t explre whether a BAA is needed t exchange infrmatin with a diabetes preventin prgram. (Link t a Business Assciates Agreement template n AMA's website.) The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

6 Engage clinicians The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

7 Yu can prevent type 2 diabetes Test yur patients fr prediabetes and refer thse at risk t an evidence-based diabetes preventin prgram Yu likely knw which f yur patients is at high risk fr type 2 diabetes. Until nw yu may nt have had a resurce t help them stp the prgressin frm prediabetes t diabetes. Nw, yu d. The American Medical Assciatin and the Centers fr Disease Cntrl and Preventin (CDC) have created a tlkit that can help physician practices screen and refer patients t evidence-based diabetes preventin prgrams withut adding a burden t yur practice. Visit preventdiabetesstat.rg t learn mre. Prgressin frm prediabetes t diabetes can take as little as five years. During that windw f time, yur patients can benefit frm a prven interventin that is part f the CDC s Natinal Diabetes Preventin Prgram (Natinal DPP). Cunsel yur patients that prediabetes is a ptentially reversible cnditin, and ne that yu can help them manage effectively by: -- Screening and Identifying patients fr prediabetes -- Referring them t a prgram that is part f the CDC s Natinal DPP This prgram is evidence-based The diabetes preventin prgram is a lifestyle interventin based n research funded by the Natinal Institutes f Health that shwed, amng thse with prediabetes, a 58 percent reductin in the number f new cases f diabetes verall, and a 71 percent reductin in new cases fr thse ver age 60. These results were achieved thrugh reducing calries, increasing physical activity, and a weight lss f just 5 t 7 percent f bdy weight t 14 punds fr a persn weighing 200 punds.* Based n strng evidence f effectiveness in reducing new-nset diabetes, the Cmmunity Preventive Services Task Frce (thecmmunityguide.rg) nw recmmends cmbined diet and physical activity prmtin prgrams like the Natinal DPP, fr peple at increased risk f type 2 diabetes. Prgram verview The prgram empwers patients with prediabetes t take charge f their health and well-being. Participants meet in grups with a trained lifestyle cach fr 16 weekly sessins and mnthly fllw-up sessins. These are NOT exercise classes. At these sessins patients learn ways t incrprate healthier eating and mderate physical activity, as well as prblem-slving, stress-reductin and cping skills int their daily lives. See next page t determine which f yur patients is eligible fr the diabetes preventin prgram. In the average primary care practice it s likely ne-third f patients ver age 18, and half ver age 65, have prediabetes. * Visit t learn mre abut this research

8 Lcating a prgram Prgrams are ffered in varied lcatins such as lcal YMCAs, cmmunity centers, faith-based rganizatins, hspitals and wrksites, and are als available nline. Find a prgram fr yur patients at cdc.gv/diabetes/preventin. Eligibility fr the diabetes preventin prgram A. Inclusin criteria: - Current age 18 years and - Mst recent BMI 24* ( 22 if Asian) and - A psitive lab test result within previus 12 mnths: HbA1C % (LOINC cde ) r FPG mg/dl (LOINC cde ) r OGTT mg/dl (LOINC cde ) r -- Histry f gestatinal diabetes (ICD-9: V12.21) B. Exclusin criteria: -- Current diagnsis f diabetes (ICD-9: 250.xx) r -- Current Insulin use Cnsider referring eligible patients: At the time f an ffice visit, and/r By generating a list f eligible patients frm yur electrnic health recrd using a structured query Physicians and ther health care prviders shuld als use their independent judgment when referring t a diabetes preventin prgram. *Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

9 Engage patients The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

10 Patient risk assessment ArE yu AT risk Fr Type 2 Diabetes? Diabetes Risk Test Hw ld are yu? Less than 40 years (0 pints) years (1 pint) years (2 pints) 60 years r lder (3 pints) Are yu a man r a wman? Man (1 pint) Wman (0 pints) If yu are a wman, have yu ever been diagnsed with gestatinal diabetes? Yes (1 pint) N (0 pints) D yu have a mther, father, sister, r brther with diabetes? Yes (1 pint) N (0 pints) Have yu ever been diagnsed with high bld pressure? Yes (1 pint) N (0 pints) Are yu physically active? Yes (0 pints) N (1 pint) What is yur weight status? (see chart at right) If yu scred 5 r higher: Yu are at increased risk fr having type 2 diabetes. Hwever, nly yur dctr can tell fr sure if yu d have type 2 diabetes r prediabetes (a cnditin that precedes type 2 diabetes in which bld glucse levels are higher than nrmal). Talk t yur dctr t see if additinal testing is needed. Write yur scre in the bx. Add up yur scre. Type 2 diabetes is mre cmmn in African Americans, Hispanics/ Latins, American Indians, and Asian Americans and Pacific Islanders. Fr mre infrmatin, visit us at r call DIABETES Visit us n Facebk Facebk.cm/AmericanDiabetesAssciatin Height Weight (lbs.) (1 Pint) (2 Pints) (3 Pints) Yu weigh less than the amunt in the left clumn (0 pints) Adapted frm Bang et al., Ann Intern Med 151: , Original algrithm was validated withut gestatinal diabetes as part f the mdel. Lwer yur risk The gd news is that yu can manage yur risk fr type 2 diabetes. Small steps make a big difference and can help yu live a lnger, healthier life. If yu are at high risk, yur first step is t see yur dctr t see if additinal testing is needed. Visit diabetes.rg r call DIABETES fr infrmatin, tips n getting started, and ideas fr simple, small steps yu can take t help lwer yur risk. Cpyright American Diabetes Assciatin. Used with permissin. 9

11 CDC Prediabetes Screening Test COULD YOU HAVE PREDIABETES? Prediabetes means yur bld glucse (sugar) is higher than nrmal, but nt yet diabetes. Diabetes is a serius disease that can cause heart attack, strke, blindness, kidney failure, r lss f feet r legs. Type 2 diabetes can be delayed r prevented in peple with prediabetes thrugh effective lifestyle prgrams. Take the first step. Find ut yur risk fr prediabetes. Yes N TAKE THE TEST KNOW YOUR SCORE! Answer these seven simple questins. Fr each Yes answer, add the number f pints listed. All N answers are 0 pints Are yu a wman wh has had a baby weighing mre than 9 punds at birth? D yu have a sister r brther with diabetes? D yu have a parent with diabetes? Find yur height n the chart. D yu weigh as much as r mre than the weight listed fr yur height? Are yu yunger than 65 years f age and get little r n exercise in a typical day? Are yu between 45 and 64 years f age? Are yu 65 years f age r lder? Add yur scre and check the back f this page t see what it means. Height AT-RISK WEIGHT CHART Weight Punds Height Weight Punds

12 IF YOUR SCORE IS 3 TO 8 POINTS This means yur risk is prbably lw fr having prediabetes nw. Keep yur risk lw. If yu re verweight, lse weight. Be active mst days, and dn t use tbacc. Eat lw-fat meals with fruits, vegetables, and whle-grain fds. If yu have high chlesterl r high bld pressure, talk t yur health care prvider abut yur risk fr type 2 diabetes. IF YOUR SCORE IS 9 OR MORE POINTS This means yur risk is high fr having prediabetes nw. Please make an appintment with yur health care prvider sn. HOW CAN I GET TESTED FOR PREDIABETES? Individual r grup health insurance: See yur health care prvider. If yu dn t have a prvider, ask yur insurance cmpany abut prviders wh take yur insurance. Deductibles and cpays may apply. Medicaid: See yur health care prvider. If yu dn t have a prvider, cntact a state Medicaid ffice r cntact yur lcal health department. Medicare: See yur health care prvider. Medicare will pay the cst f testing if the prvider has a reasn fr testing. If yu dn t have a prvider, cntact yur lcal health department. CS232302A 11

13 have prediabetes Yu culd be ne f them. Having prediabetes means yu are at increased risk fr develping serius health prblems such as type 2 diabetes, strke and heart disease. Yu culd have prediabetes if yu have: High chlesterl r High bld pressure r A parent, brther r sister with diabetes Yur risk ges up if yu are als verweight, and/r ver age 45. If yu have prediabetes, we can help! Ask yur dctr hw yu can stp diabetes befre it starts. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes. 12

14 Are yu at risk fr prediabetes? 1 in 3 U.S. adults has prediabetes. Mst dn t knw it. Are yu at risk? Yu may have prediabetes and be at risk fr type 2 diabetes if yu: Are 45 years f age r lder Are verweight Have a family histry f type 2 diabetes Have high bld pressure Are physically active fewer than three times per week Ever had diabetes while pregnant (gestatinal diabetes) r gave birth t a baby that weighed mre than 9 punds The Natinal Diabetes Preventin Prgram can help! The Natinal Diabetes Preventin Prgram (Natinal DPP) uses a prgram that is prven t prevent r delay type 2 diabetes, and will help yu lwer yur risk by imprving yur fd chices and increasing physical activity. Hw des it wrk? As part f a grup in yur cmmunity r nline, yu will wrk with a trained lifestyle cach t learn the skills yu need t make lasting lifestyle changes. Yu will learn t eat healthy, add physical activity t yur life, manage stress, stay mtivated and slve prblems that can get in the way f healthy changes. Prediabetes can lead t serius health prblems Having prediabetes means yur bld glucse (sugar) level is higher than nrmal, but nt high enugh t be diagnsed as diabetes. But, nearly 90 percent f adults wh have prediabetes dn t knw they have it. If yu have prediabetes and dn t lse weight r increase yur physical activity, yu culd develp type 2 diabetes within five years. Type 2 diabetes is a serius cnditin that can lead t health issues such as heart attack, strke, blindness, kidney failure, r lss f tes, feet r legs. What can yu d? Talk t yur dctr abut yur risk f having prediabetes. Here s the gd news If yu have prediabetes, yur dctr may refer yu t a prven lifestyle change prgram that can help yu prevent r delay getting type 2 diabetes. Features Trained cach t guide and encurage yu In-persn r nline CDC-apprved prgram Supprt frm thers wrking n the same gals as yu Skills t help yu lse weight, be mre physically active and manage stress Sme insurance cmpanies will cver What participants are saying I lve having a lifestyle cach. She has given us great infrmatin, helped me stay n track and stay psitive! -----Bruce I m s excited because I went t the dctr last week and all f my numbers were dwn and I fficially n lnger have prediabetes Vivien Nw is the time t take charge f yur health and make a change! Ask yur dctr r nurse. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

15 S yu have prediabetes nw what? Prediabetes means yur bld glucse (sugar) level is higher than nrmal, but nt high enugh t be diagnsed as diabetes. This cnditin raises yur risk f type 2 diabetes, strke and heart disease. What can yu d abut it? The gd news is that there s a prgram that can help yu. The Natinal Diabetes Preventin Prgram, led by the Centers fr Disease Cntrl and Preventin (CDC), uses a methd prven t prevent r delay type 2 diabetes. By imprving fd chices and increasing physical activity, yur gal will be t lse 5 t 7 percent f yur bdy weight-----that is 10 t 14 punds fr a persn weighing 200 punds. These lifestyle changes can cut yur risk f develping type 2 diabetes by mre than half. Hw des the prgram wrk? As part f a grup, yu will wrk with a trained diabetes preventin cach and ther participants t learn the skills yu need t make lasting lifestyle changes. Yu will learn t eat healthy, add physical activity t yur life, manage stress, stay mtivated and slve prblems that can get in the way f healthy changes. The prgram lasts ne year, with 16 sessins taking place abut nce a week and six t eight mre sessins meeting nce a mnth. By ging thrugh the prgram with thers wh have prediabetes yu can celebrate each ther s successes and wrk tgether t vercme challenges. Sme insurance plans will cver the cst f the prgram. Check with yur insurance prvider t see if it is cvered. Als, sme places that prvide the prgram will adjust the fee yu pay based n yur incme. Why shuld yu act nw? Withut weight lss and mderate physical activity, many peple with prediabetes will develp type 2 diabetes within five years. Type 2 diabetes is a serius cnditin that can lead t health issues such as heart attack, strke, blindness, kidney failure, r lss f tes, feet r legs. NOW is the time t take charge f yur health and make a change. Features f the prgram: A trained cach t guide and encurage yu A CDC-apprved prgram Grup supprt Skills t help yu lse weight, be mre physically active and manage stress What participants are saying I lve having a lifestyle cach. She has given us great infrmatin, helped me stay n track and stay psitive! -----Bruce I m s excited because I went t the dctr last week and all f my numbers were dwn and I fficially n lnger have prediabetes Vivien Sign up tday fr a prgram near yu! T find a prgram in ur area that is part f the Natinal Diabetes Preventin Prgram, visit cdc.gv/diabetes/ preventin. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

16 Letter template Use/adapt these templates t cnduct efficient fllw-up and referral with patients wh have been identified as having prediabetes <<YOUR LET TERHEAD>> <<ADDRESS>> <<PHONE NUMBER>> <<DATE>> <<PATIENT NAME>> <<PATIENT ADDRESS>> Dr. Mr./Mrs. <<PATIENT LAST NAME>>, Thank yu fr being a patient f the <<PRACTICE NAME HERE>>. We are writing t tell yu abut a service t help make yur health better. Based n ur review f yur medical chart, yu have a cnditin knwn as prediabetes. This means yur bld sugar is higher than nrmal, which increases yur risk f develping serius health prblems including type 2 diabetes, as well as heart disease and strke. We have sme gd news. Our ffice wants yu t knw that yu may be eligible fr a diabetes preventin prgram run by ur partners, <<NAME OF PROGRAM PROVIDER>>. This prgram is prven t reduce yur risk f develping diabetes and ther health prblems. We have sent a referral t <<NAME OF PROGRAM PROVIDER>> and smene will call yu t discuss the prgram, answer any questins yu may have and, if yu are interested, enrll yu in the prgram. Please feel free t give <<NAME OF PROGRAM PROVIDER>> a call at <<PHONE NUMBER>>. -- OR-- We have sent a referral t <<NAME OF PROGRAM PROVIDER>> and we urge yu t call <<PHONE NUMBER>> t learn mre abut the prgram and enrll. We hpe yu will take advantage f this prgram, which can help prevent yu frm develping serius health prblems. Sincerely, Dr. <<PHYSICIAN LAST NAME>> The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

17 Sample Talking pints fr phne utreach Hell <<PATIENT NAME>>. I am calling frm <<PRACTICE NAME HERE>>. I m calling t tell yu abut a prgram we d like yu t cnsider, t help yu prevent sme serius health prblems. Based n ur review f yur medical chart, yu have a cnditin knwn as prediabetes. This means yur bld sugar is higher than nrmal, which makes yu mre likely t develp serius health prblems including type 2 diabetes, strke and heart disease. We have sme gd news, t. Yu may be eligible fr a diabetes preventin prgram run by ur partners, <<NAME OF PROGRAM PROVIDER>>. -- Their prgram is based n research prven t reduce yur risk f develping diabetes and ther health prblems. Optin A We have sent a referral t <<NAME OF PROGRAM PROVIDER >> and smene will call yu t discuss the prgram, answer any questins yu may have and, if yu are interested, enrll yu in the prgram. Please feel free t give <<NAME OF PROGRAM PROVIDER>> a call at <<PHONE NUMBER>>. D yu have any questins fr me? Thank yu fr yur time and be well. Optin B We have sent a referral t <<NAME OF PROGRAM PROVIDER>> and we urge yu t call <<PHONE NUMBER>> t learn mre abut the prgram and enrll. We hpe yu will take advantage f this prgram, which can help prevent yu frm develping serius health prblems. D yu have any questins fr me? Thank yu fr yur time and be well. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

18 Incrprate screening, testing and referral int practice The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

19 M.A.P. (Measure, Act, Partner) THE M.A.P. (Measure, Act, Partner) t prevent type 2 diabetes-----physicians and care teams can use this dcument t determine rles and respnsibilities fr identifying adult patients with prediabetes and referring t cmmunity-based diabetes preventin prgrams. Pint-f-Care and Retrspective methds may be used tgether r alne. Chse and check what wrks best fr yur practice Step 1: Measure When Wh Hw (draw frm AMA-CDC tls) Pint-f-care methd Assess risk fr prediabetes during rutine ffice visit Test and evaluate bld glucse level based n risk status At the frnt desk During vital signs Receptinist Medical assistant Nurse Physician Other Prvide Are yu at risk fr prediabetes? patient educatin handut in waiting area Use/adapt Patient flw prcess tl Use CDC r ADA risk assessment questinnaire at check-in Display 8 x 11 patient-facing pster prmting prediabetes awareness t yur patients Use/adapt Pint-f-care algrithm Retrspective methd Query EHR t identify patients with BMI 24* and bld glucse level in the prediabetes range Step 2: Act Every mnths Health IT staff Other Use/adapt Retrspective algrithm Pint-f-care methd Cunsel patient re: prediabetes and treatment ptins during ffice visit Refer patient t diabetes preventin prgram Share patient cntact inf with prgram prvider** During the visit Medical assistant Nurse Physician Other Advise patient using S yu have prediabetes nw what? handut Use/adapt Health care practitiner referral frm Refer t Cmmnly used CPT and ICD cdes Retrspective methd Infrm patient f prediabetes status via mail, r phne call Make patient aware f referral and inf sharing with prgram prvider Refer patient t diabetes preventin prgram Share patient cntact inf with prgram prvider** Cntact patient sn after EHR query Health IT staff Medical assistant (fr phne calls) Other Use/adapt Patient letter/phne call template Use/adapt Health care practitiner referral frm fr making individual referrals Use/adapt Business Assciate Agreement template n AMA's website if needed Step 3: Partner With diabetes preventin prgrams Engage and cmmunicate with yur lcal diabetes preventin prgram Establish prcess t receive feedback frm prgram abut yur patients participatin Establish cntact befre making 1st referral Medical assistant Nurse Physician Other Use/adapt Business Assciate Agreement template n AMA's website if needed Refer t Cmmnly used CPT and ICD cdes With patients Explre mtivating factrs imprtant t the patient At fllw-up visit, rder/review bld tests t determine impact f prgram and reinfrce cntinued prgram participatin Discuss prgram feedback with patient and integrate int care plan During ffice visit Other Office manager Other Advise patient using S yu have prediabetes nw what? handut and prvide CDC physical activity fact sheet *Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. Fllwing the M.A.P. fr Preventing Type 2 Diabetes can help yur practice achieve Patient Centered Medical Hme (PCMH) recgnitin, as well as Meaningful Use f yur electrnic medical recrd. (Supprts PCMH recgnitin via Standard 4: Self-Care Supprt, B. Prvide Referrals t Cmmunity Resurces (3 pints), NCQA Facilitating PCMH Recgnitin, 2011.) * * T share patient cntact infrmatin with a diabetes preventin prgram, yu may need a Business Assciate Agreement (BAA). The American Medical Assciatin and the Centers fr Disease Cntrl and Preventin have created a tl kit that can help physician practices screen and refer patients t evidence-based diabetes preventin prgrams. Visit preventdiabetesstat.rg t learn mre. Physicians and ther health care prviders shuld als use their independent judgment when referring t a diabetes preventin prgram

20 Sample patient flw prcess MEASURE CHECK-IN If age >_18 and patient des nt have diabetes, prvide CDC Prediabetes Screening Test r ADA Diabetes Risk Test Patient cmpletes test and returns it Insert cmpleted test in paper chart r nte risk scre in EMR ROOMING/VITALS Calculate BMI (using table) and review diabetes risk scre If elevated risk scre r histry f GDM, flag fr pssible referral ACT EXAM/CONSULT Fllw Pint-f-care prediabetes identificatin algrithm Determine if patient has prediabetes and BMI 24* ( 22 fr Asians) r a histry f GDM Advise re: diet/exercise and determine willingness t participate in a diabetes preventin prgram If patient agrees t participate, prceed with referral PARTNER REFERRAL Cmplete and submit referral frm FOLLOW UP Cntact patient and trublesht issues with enrllment r participatin *Sme diabetes preventin prgram prviders require a BMI > 25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

21 Pint-f-care prediabetes identificatin MEASURE If patient is age 18 and des nt have diabetes, prvide self-screening test (CDC Prediabetes Screening Test r ADA Diabetes Risk Test) If self-screening test reveals risk, prceed t next step Review medical recrd t determine if BMI 24* ( 22 if Asian) r histry f GDM** NO YES If n: Patient des nt currently meet prgram eligibility requirements Determine if a HbA1C, FPG r OGTT was perfrmed in the past 12 mnths NO YES Order ne f the tests belw: Hemglbin A1C (HbA1C) Fasting plasma glucse (FPG) Oral glucse tlerance test (OGTT) RESULTS Diagnstic test Nrmal Prediabetes Diabetes HbA1C(%) < Fasting plasma glucse (mg/dl) < Oral glucse tlerance test (mg/dl) < ACT Encurage patient t maintain a healthy lifestyle. Cntinue with exam/ cnsult. Retest within three years f last negative test. Refer t diabetes preventin prgram, prvide brchure. Cnsider retesting annually t check fr diabetes nset. Cnfirm diagnsis; retest if necessary. Cunsel patient re: diagnsis. Initiate therapy. PARTNER Cmmunicate with yur lcal diabetes preventin prgram. Cntact patient and trublesht issues with enrllment r participatin. At the next visit, ask patient abut prgress and encurage cntinued participatin in the prgram. Adapted frm: New Yrk State Department f Health. New Yrk State Diabetes Preventin Prgram (NYS DDP) prediabetes identificatin and interventin algrithm. New Yrk: NY Department f Health; * Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. * * Histry f GDM = eligibility fr diabetes preventin prgram The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

22 Referring patients t a diabetes preventin prgram Methd 1: Pint-f-care identificatin and referral Dwnlad and display patient materials Dwnlad and print the practice and patient resurces included in this guide in advance f patient visits, s yur ffice can have them available in the waiting rm r during cnsult. Measure Step 1 -- During check-in: If age 18 and patient des nt have diabetes, give him/her the CDC Prediabetes Screening Test r American Diabetes Assciatin Diabetes Risk Test. After patient cmpletes the test and returns it, insert cmpleted test in the paper chart r nte risk scre in the electrnic medical recrd (EMR). Screening test can als be mailed t patient alng with ther pre-visit materials. Step 2 -- During rming/vitals: Calculate the patient s bdy mass index. Mst EMRs can calculate BMI autmatically. Review the patient s diabetes risk scre and if elevated ( 5 n ADA test r 9 n CDC test), flag fr pssible referral. Step 3 -- During exam/cnsult: Fllw the Pint-f-care prediabetes identificatin algrithm t determine if patient has prediabetes. If the bld test results d nt indicate prediabetes: Encurage the patient t maintain healthy lifestyle chices. Cntinue with exam/cnsult. Act A. If the patient screens psitive fr prediabetes and has BMI <24 * (<22 if Asian): -- Intrduce the tpic f prediabetes by briefly explaining what it is and its relatin t diabetes (use the handut S yu have prediabetes nw what? ). Review the patient s wn risk factrs. -- Emphasize the imprtance f preventin, including healthy eating, increased physical activity, and the eliminatin f risky drinking and tbacc use. (Visit the Natinal Diabetes Educatin Prgram s GAME PLAN t Prevent Type 2 Diabetes fr additinal patient resurces.) B. If the patient screens psitive fr prediabetes and has BMI 24 ( 22 if Asian): -- Fllw the steps in A abve, discuss the value f participating in a diabetes preventin prgram, and determine the patient s willingness t let yu refer him/her t a prgram. -- If the patient agrees, cmplete and send the referral frm t a cmmunity-based r nline diabetes preventin prgram, depending n patient preference. -- If patient declines, ffer him/her a prgram handut and re-evaluate risk factrs at next clinic visit. Step 4 -- Referral t diabetes preventin prgram: Mst diabetes preventin prgrams are cnfigured t receive referrals via cnventinal fax (ver a phne line) r secure . Cmplete the referral frm and submit t a prgram as fllws: A. If using a paper referral frm, send via fax (ver a phne line) r scan and B. If the referral frm is embedded in yur EMR, either fax (ver a phne line) r using the EMR -- Sme diabetes preventin prgrams can als receive an e-fax (ver the Internet) Physicians and ther health care prviders shuld als use their independent judgment when referring t a diabetes preventin prgram. Partner Step 5 -- Fllw-up with patient: Cntact patient and trublesht issues with enrllment r participatin. At the next visit, ask patient abut prgress and encurage cntinued participatin in the prgram. * Sme diabetes preventin prgram prviders require a BMI >25. Please chek with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

23 Retrspective prediabetes identificatin MEASURE Query EMR r patient database every mnths using the fllwing criteria: A. Inclusin criteria: - Age 18 years and - Ms t recent BMI 24*( 22 if Asian) and - A psitive lab test result within previus 12 mnths: HbA1C % (LOINC cde ) r FPG mg/dl (LOINC cde ) r OGTT mg/dl (LOINC cde ) r -- Histry f gestatinal diabetes (ICD-9: V12.21) B. Exclusin criteria: -- Current diagnsis f diabetes (ICD-9: 250.xx) r -- Current Insulin use Generate a list f patient names with relevant infrmatin ACT Use the patient list t: A. Cntact patients t infrm f risk status, explain prediabetes, and share inf n diabetes preventin prgrams, and/r B. Send patient inf t diabetes preventin prgram prvider -- Prgram crdinatr will cntact patient directly, and C. Flag medical recrd fr patient s next ffice visit PARTNER Discuss prgram participatin at next visit *Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

24 Methd 2: Retrspective identificatin and referral Step 1 -- Query EMR r patient database Measure Query yur EMR r patient database every mnths using the fllwing criteria: A. Inclusin criteria: - Ag e 18 years and - B MI 24* ( 22 if Asian) and -- A psitive test result fr prediabetes within the preceding 12 mnths: HbA1C % r Fasting plasma glucse mg/dl r Oral glucse tlerance test mg/dl r -- Clinically diagnsed gestatinal diabetes during a previus pregnancy B. Exclusin criteria: -- Current diagnsis f diabetes r -- Current Insulin use Generate a list f patient names and ther infrmatin required t make referrals: -- Gender and birth date -- address -- Mailing address -- Phne number Act Step 2 -- Referral t diabetes preventin prgram A. Cntact patients via phne, , letter r pstcard t explain their prediabetes status and let them knw abut the diabetes preventin prgram. B. Send relevant patient infrmatin t yur lcal (r nline) diabetes preventin prgram crdinatr and have him/her cntact the patient directly (may require Business Assciate Agreement). C. Flag patients medical recrds fr their next ffice visit. Physicians and ther health care prviders shuld als use their independent judgment when referring t a diabetes preventin prgram. Partner During the next ffice visit, discuss diabetes preventin prgram participatin: -- If the patient is participating, discuss prgram experience and encurage cntinued participatin -- If the patient has declined t participate, stress the imprtance f lifestyle change and cntinue t encurage participatin (use the handut S yu have prediabetes nw what? ) * Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements. The American Medical Assciatin and the Centers fr Disease Cntrl are supprting physicians, care teams and patients t prevent diabetes

25 Health care practitiner referral frm t a diabetes preventin prgram Send t: Fax: PATIENT INFORMATION First name Last name Health insurance Address City Gender Male Female State Birth date (mm/dd/yy) ZIP cde Phne By prviding yur infrmatin abve, yu authrize yur health care practitiner t prvide this infrmatin t a diabetes preventin prgram prvider, wh may in turn use this infrmatin t cmmunicate with yu regarding its diabetes preventin prgram. PRACTITIONER INFORMATION (COMPLETED BY HEALTH CARE PRACTITIONER) Physician/NP/PA Practice cntact Phne Fax SCREENING INFORMATION Bdy Mass Index (BMI) Address City State ZIP cde Bld test (check ne) Eligible range Test result (ne nly) Hemglbin A1C % Fasting Plasma Glucse mg/dl 2-hur plasma glucse (75 gm OGTT ) mg/dl Date f bld test (mm/dd/yy): Eligibility = >24* (>22 if Asian) Fr Medicare requirements, I will maintain this signed riginal dcument in the patient s medical recrd. Date OPTIONAL Practitiner signature By signing this frm, I authrize my physician t disclse my diabetes screening results t the (insert prgram/rganizatin name here) fr the purpse f determining my eligibility fr the diabetes preventin prgram and cnducting ther activities as permitted by law. I understand that I am nt bligated t participate in this diabetes screening prgram and that this authrizatin is vluntary. I understand that I may revke this authrizatin at any time by ntifying my physician in writing. Any revcatin will nt have an effect n actins taken befre my physician received my written revcatin. Date Patient signature IMPORTANT WARNING: The dcuments accmpanying this transmissin cntain cnfidential health infrmatin prtected frm unauthrized use r disclsure except as permitted by law. This infrmatin is intended nly fr the use f the individual r entity named abve. The authrized recipient f this infrmatin is prhibited frm disclsing this infrmatin t any ther party unless permitted t d s by law r regulatin. If yu are nt the intended recipient and have received this infrmatin in errr, please ntify the sender immediately fr the return r destructin f these dcuments. Rev. 05/30/14 * Sme diabetes preventin prgram prviders require a BMI >25. Please check with yur diabetes preventin prgram prvider fr eligibility requirements

26 BMI calculatin chart WEIGHT HEIGHT 5'0" '1" '2" '3" '4" '5" '6" '7" '8" '9" '10" '11" '0" '1" '2" '3" '4" '5" Blue Underweight: Less than 18.5 Green Healthy Weight: Yellw Overweight: Orange Obese: Red Extreme Obesity: 40 r greater BMI stands fr BODY MASS INDEX which is an estimate f ttal bdy fat based n height and weight. It is used t screen fr weight categries that may lead t health prblems. THE GOAL fr mst peple is t have a BMI in the green area. It is usually best fr yur BMI t stay the same ver time r t gradually mve tward the green area

27 Cdes: When screening fr prediabetes and diabetes Cdes fr prediabetes and diabetes screening *,, Internatinal Classificatin f Diseases (ICD)-9 fr diabetes screening Current Prcedural Terminlgy (CPT ) fr diabetes screening tests V77.1 Diabetes Screening CPT Fasting Plasma Glucse Test Abnrmal Glucse CPT Pst-meal Glucse (2-hur plasma glucse; 2hPG; 2 hr specimen) Impaired Fasting Glucse CPT Oral Glucse Tlerance (3 specimens with 2 hr value included) Impaired Glucse Tlerance (ral) Other Abnrmal Glucse NEC Obesity Overweight CPT CPT 83036QW Hemglbin A1C Hemglbin A1C (used fr POC test that is CLIA waived [~DCA]) These cdes may be useful t reprt services/tests perfrmed t screen fr prediabetes and diabetes. References * New Yrk State Department f Health. New Yrk State Diabetes Preventin Prgram (NYS DPP) prediabetes identificatin and interventin algrithm. New Yrk: NY Dept f Health; American Diabetes Assciatin. Standards f medical care in diabetes Diabetes Care. January 2013; 36:S di: /dc13-S011 Ackermann RT. Cding Guide fr Diabetes and Prediabetes Testing (Published here with permissin frm Rnald T. Ackermann MD, MPH.) 2015 American Medical Assciatin. CPT is cpyright 2014 American Medical Assciatin. All rights reserved