Medicare and Medicaid Services
APA format. MUST BE 1 SEPERATE RESPONSE TO EACH QUESTION. 1 paragraph per response. Use only scholar authors only
Discussion 1:
As the staff nurse charged with this task I would first find out the latest HEDIS comprehensive diabetes care guidelines. In looking there are four primary components to monitor and those billing codes could be run for reports to assess the diabetic population and if the office is meeting goals. According to the national committee for quality assurance (NCQA) the key components to measure for successful care are A1C (goal is < 8.0% in most cases), a retinal eye exam, medical attention for neuropathy, and getting a goal blood pressure < 140/90 (NCQA, 2020). Assessing billing codes for these four measures both within goal and outside goal will give the office an idea of where care is meeting, exceeding and failing to meet.
According to the CDC 10.5% of the United States population has diabetes, with about 21% of those undiagnosed and 34.5% of the United States population being prediabetic (CDC, 2020). Knowing this should push to assess patients with risk factors on a regular basis to catch the disease process early and prevent complications. Pulling regular reports on risk factors for diabetes would help the office become proactive in treatment.
If the office wished to pursue those that have previously come to the clinic and have not had an exam since the move the EMR it would require a team dedicated to manually gather data from paper charts. This would be beneficial if an at risk person had yet to come back to the clinic for their yearly exam. It would allow the staff to re-establish a connection with former clients and possibly grow the practice in the process. The location of the clinic could have an impact on how a follow up call is received. It was found that in more urban clinics patient physician relationships are more “cure oriented” or the physician doing more disease specific questions and answers during the visits where in a rural community they are more “care-oriented communication” or trust building emotional connections (Desjarlais-deKlerk & Wallace, 2013). Those in the rural communities would consider a follow-up call a caring gesture where those more urban may consider it less desirable. Either way, follow through with inactive clients would benefit the overall health of the country.
Discussion 2:
The Center for Medicare and Medicaid Services ( CMS) collaborated with the National Committee of Quality Assurance (NCQA) to develop a strategy that would evaluate the quality of care provided by Chronic condition special needs programs (SNPs). The NCQA established Healthcare Effectiveness Data and Information Set (HEDIS), which measures precisely for SNPs. HEDIS is a comprehensive set of standardized performance measures designed to provide healthcare providers and patients with the information they need for reliable comparison of health plan performance (Center for Medicare and Medicaid Services 2019). This care plan is used for patient care and management of specific chronic conditions: cancer, heart disease, diabetes, dementia, and asthma, to name a few. These SNPs can be used by HEDIS performance data to monitor the success of quality improvement initiatives, track improvement, provide data for areas of improvement, and provide a set of measurable standards.
The comprehensive diabetes care according to HEDIS is a measurement that examines the percentage of patients ages 18-75 with Diabetes Type 1 and 2 who had the following: Hemoglobin A1C testing, retinal eye exam, medical attention for neuropathy, and blood pressure control of less than 140/90 (National Committee of Quality Assurance 2020). The medical staff can receive help with nursing students or medical assistant students if available to audit charts for the above criteria. I would devise an audit sheet with a checklist according to HEDIS and check it off if those four interventions were met; any interventions that were not met could be ordered on the patient’s next visit. I would have the billing office print me a list of patients that had medical codes that match the criteria as well. Since the office recently went to an EMR system, I would run an audit on there. All information gathered could be given to a nurse responsible for inputting the data into a bar chart for easy access. Using the printed list, I would assign each staff; 2 nurses and the MA 10 paper charts a day to audit a day. I would have the billing office audit the charts for the patients that will be seen the next day, the day before. Making sure all charts were up to date would rely on healthcare staff; the physicians’ role would be to order any intervention needed for patients with the information that would be provided. This task would take about 1-2 months, depending on the daily workload. Auditing all the hard copies of the chart would be time-consuming, but this would ensure that all charts would be updated, and the result will be improved patient care and outcomes.
