Rural Diabetes Clinic Case Study

The Rural Diabetes Clinic (RDC) is in a rural community in Oklahoma and serves a population primarily of American Indian descent. The RDC currently does not meet the benchmark goals of the Clinical Quality Measures (CQM) – improvement activities for Hemoglobin A1c (HbA1c) levels in the diabetic patients, ages 18 to 75.
The Need for Policy and Guideline Change
The federal benchmark goals for diabetic patients of the ages 18-75 is for HbA1c levels less than 9% are 0%. This means the patients for a healthcare organization must all have HbA1c levels less than 9% to be eligible for the maximum adjustment of Medicare part B reimbursement through the Merit-Based Incentive Payment System (MIPS) for health services (Centers for Medicare and Medicaid

Services [CMS] and the Office of the National Coordinator for Health Technology [ONC], 2017).
The benchmark percentages of patients with a HbA1c level below 9% for the RDC is 88%. This means 12% of the RDC patients have a HbA1c level above 9%, which falls below the benchmark goals for the MIPS and a penalty of 4% of the reimbursements for healthcare services may be incurred (CMS, 2017). The underperformance of the benchmark goal may affect the RDC financially. The potential for financial constraints may warrant the reduction of staff, healthcare professionals, and healthcare services, which jeopardizes the quality of patient care (Lee, 2017).
The potential for the RDC patients to experience a decrease in the quality of care necessitates a change policy proposal with guidelines/strategies. The change policy proposal with guidelines/strategies is to engage the diabetic patients in diabetic disease management, to decrease HbA1c levels, and to ensure the quality of patient care.
The Solution
The evidence-based literature suggest to improve performance benchmarks for the diabetic patient is to utilize strategies that engage the patient with culturally sensitive communication and patient-centered care (American Diabetes Association, 2016; Powers et al., 2015). Additionally, the evidence-based strategies would improve performance benchmarks and would comply with local, state, and federal healthcare laws and policies.
The evidence-based strategies are based on the local, state, and federal healthcare laws to improve the health of the population through quality healthcare, safety, and at a lower cost (Santilli & Vogenberg, 2015; United States Department of Health and Human Services [USHHS], 2018). The evidence-based strategies have been proven to meet the standards of the local, state, and federal laws and policies (American Diabetes Association, 2016; USHHS, 2018). Furthermore, implementing strategies that adhere to the QCM and quality performance standards set forth by the CMS, ensures the strategies comply with healthcare regulation laws and policies (Santilli & Vogenberg, 2015; USHHS, 2018).
The implementation of the strategies would be through a diverse interprofessional team approach (American Diabetes Association, 2016). This would guarantee the guideline/strategies are holistic, patient-centered, and culturally inclusive through a multi-perspective approach (Gucciardi, Espin, Morganti, & Dorado, 2016). Additionally, the policy and guideline/strategies would consider the potential for the unknown and environmental factors that may affect the implantation of the evidence-based strategies (Gucciardi et al., 2016).
The Potential Effects of Environmental Factors
The potential effects of environmental factors such as regulatory influences and organization resources may affect the quality performance strategies to improve performance benchmarks for HbA1c.

The regulatory considerations and the MIPS criteria for receiving reimbursement for health services will influence the financial abilities of the RDC to provide resources such as adequate staffing and health services (Santilli & Vogenberg, 2015). For instance, if the MIPS criteria are not met for HbA1c then the reimbursement for health services decreases, which affects the RDC’s ability to retain staff and provide quality health services. Hence, the policy and guidelines/strategies for the RDC must be realistic, streamlined, and adaptable to the environmental factors to improve the health of the patients and the community.
Policy and Guidelines
The proposed change policy to improve performance benchmarks for HbA1c is:
• To provide high-quality care for the RDC diabetic patient is through an interprofessional team approach for delivering, monitoring, managing, and evaluating patient care to improve HbA1c levels and adherence to diabetic disease management treatment plans through culturally inclusive patient engagement (USHHS, 2018).
The guidelines/strategies for the change policy to improve benchmarks for the HbA1c for the RDC patients are:
• Develop a diverse interprofessional team that represents the diversity of the community’s population and provide culturally competent education for the team members (Akiyode & Davis, 2015; Gucciardi et al.,

2016).
• Deliver patient-centered care with the integration of the AI cultural beliefs, inclinations, readiness to learn, and is communicated in a culturally sensitive manner that is understandable to the patient. Additionally, education materials and resources must be appropriate for the culture, age, reading ability level, and meet the learning needs of the patient (Akiyode & Davis, 2015; Gucciardi et al., 2016; Powers et al., 2015; Santilli & Vogenberg, 2015).
• Engage and encourage the patient to adhere to the treatment plans through culturally sensitive and patient-centered communication. Additionally, allow the decisions for the treatment options to be patient-centered, shared decisions, and adaptable to the patient’s cultural beliefs and desires when appropriate (Akiyode & Davis, 2015; American Diabetes Association, 2016; Powers et al., 2015).
• Provide increased access to healthcare for the AI which may include extended clinic hours, telehealth, or home visits to encourage adherence to disease management treatment plans (Powers et al., 2015).
• Evaluate the policy and guidelines through the dashboard data of the electronic medical records and patient surveys. Revise the policy and guidelines as needed to improve performance benchmarks (USHHS, 2018).
Identification of Stakeholders
The stakeholders who should be involved in the development and implementation of the change policy and guidelines/strategies are the interprofessional team, the staff, the patients, and the healthcare organization that supports the RDC (Gucciardi et al., 2016; USHHS, 2018). It is important to engage these stakeholders to ensure the policy and guidelines/strategies are patient-centered, culturally competent, and meet the local, state, and federal laws to procure financial stability and to ensure the improvement of performance benchmarks (Santilli & Vogenberg, 2015; USHHS, 2018). Furthermore, engaging all stakeholders allows a multi-perspective that incorporates the local culture with the desired outcomes of the RDC to ensure a smoother implementation of the policy and guidelines, patient adherence, and improve communication amongst the stakeholders (Akiyode & Davis, 2015; Gucciardi et al., 2016). This safeguards the success of the RDC and improves the health of the AI and the community.
Conclusion
The RDC serves a small community with a dominant population of AI. The current issue is the underperformance of the improvement activity of HbA1c less than 9%. The performance benchmark does not meet the MIPS criteria for maximum reimbursement. This affects the financial resources for the RDC and potentially jeopardizes the quality of patient care due to the potential reduction of staff and health services. However, the new policy and guidelines/strategies are culturally competent, patient-centered, and engages all stakeholders. The new policy and guidelines/strategies are designed to improve the performance benchmarks for HbA1c. However, it is up to the interprofessional team members and the staff to engage the patients and deliver high-quality care to improve patient outcomes and ensure patient adherence, which will preserve the AI culture of the RDC’s community for future generations.