Module 4: Action - Learning From Activities Underway (continued, 3)

Diabetes Care Quality Improvement: A Resource Guide for State Action

State Approaches to Diabetes Care Quality Improvement (continued)

Profiles of Selected Best Practice States

This section examines the mix of programs that four different States DPCPs use to improve diabetes care quality. The States profiled here were selected based on a variety of criteria. A list of high-performing States was developed based on rankings in the NHQR on diabetes care quality. This list was supplemented by information on best practices from the CDC, the Assistant Surgeon General's office, and research on other innovative diabetes quality improvement programs. From this list a cross section of States was selected that represented different areas of the country, geographic and population differences, and baselines for diabetes care quality. Some the States listed below score well on diabetes quality of care measures in the NHQR. Others are below national averages according to NHQR data. Thus, these States demonstrate real-world approaches to improving diabetes care that attempt to surmount the challenges that States face.


California uses a variety of approaches and partnerships to address diabetes in the State. The State's Medicaid program, MediCal, identified diabetes as a high-cost disease. The DPCP investigated the effect of case management on the Medicaid population. The 4-year study showed that case management resulted in a significant reduction in HbA1c levels (California Medi-Cal Type 2 Diabetes Study Group, 2004). Now that the DPCP has shown that this strategy works, it is working on funding for a study that will help determine whether this effort would be cost effective and feasible throughout the Medicaid population.

The California Cooperative Healthcare Reporting Initiative (CCHRI) is an innovative public-private partnership that has developed a program for measuring diabetes quality of care (go to box below). California is part of the HRSA Health Disparities Collaborative which works with community clinics on diabetes care. The California Primary Care Association expanded the program to include more clinics with the funding support of the California Health Care Foundation. California is also one of five States involved in the HRSA sponsored diabetes collaboratives that focused on identifying pre-diabetes. California also uses NDEP educational materials and is participating in the national Diabetes Detection Initiative (DDI) of the U.S. Department of Health and Human Services. The primary focus of this initiative is to help people understand their diabetes risk by knowing the risk factors and assist high-risk people in linking with various health care systems and health care professionals to discuss testing.

California has evaluated the success of its efforts through multiple methods that identify short-term, long-term and process outcomes. The State is following CDC's logic modeling, looking at data to inform and help guide future efforts. They are using measures that are already being collected and then deriving ways to fill in the gaps. In addition to quantitative data, California is collecting qualitative information through focus groups and surveys of partners about the effectiveness of communications and messages.


California's Diabetes Continuous Quality Improvement Project

In an effort to address problems with undiagnosed diabetes and gaps in quality for diabetes care, the California Cooperative Healthcare Reporting Initiative (CCHRI) created the Diabetes Continuous Quality Improvement Project (Diabetes CQI). The CCHRI is an alliance of purchasers, health plans and providers in California that seek to improve health care quality through collecting performance data, providing a forum for all sectors of the health care industry to collaborate on quality improvement, and disseminating information to a variety of audiences. CCHRI is administered by the Pacific Business Group on Health (PBGH).

A unique collaboration of purchasers, health plans, and providers, California's Diabetes CQI project seeks to:

  • Improve identification of diabetes.
  • Improve data exchange between providers and health plans.
  • Improve routine monitoring and testing of diabetes patients.
  • Show measurable improvements in the health of diabetes patients.
  • Develop a toolkit of interventions to help achieve project objectives.
  • Evaluate the effectiveness of project interventions.
  • Standardize clinical guidelines to create efficiencies across providers.
  • Promote information sharing and best practices.

Collaborators in the Diabetes CQI include the State's largest employer coalition, the Pacific Business Group on Health, as well as seven of California's largest health plans and 24 medical groups and independent practice associations. The California State DPCP is involved as a partner in the project and has provided diabetes expertise as well as a public health perspective to the business model being used by private sector groups. Collaborators have agreed on common treatment guidelines for diabetes (developed by DPCP and Diabetes Coalition of California) that are in agreement with ADA clinical practice recommendations and a common toolkit of interventions, eliminating confusion and conflicting information from different sources.

Different parts of the project's overall objectives are accomplished through several programs:

  • The Quality Improvement, Learning and Teaching program (QUILT) provides support to provider groups that are fostering population-based practice improvements. Site visits and initial assessments, monthly teleconferences, quarterly meetings and individualized consultation help advance quality improvements in clinical settings.
  • The Clinical Benchmarking Study collects data on the quality of care provided to people with diabetes by the 24 provider organizations. Provider organizations and employers can use the information to track improvements in care over time, improve disease management interventions, and identify and disseminate best practices.
  • The project developed a common Intervention Toolkit for providers that includes patient and provider education materials, medical chart inserts and checklists, and other tools to improve clinical care quality. More than 300 tools were evaluated for a variety of clinical criteria and then evaluated for ease of use. The project arrived at 40 reliable resources that it included in the Intervention Toolkit, distributed it to plans and providers, and provided training on how to use it.

Legislative Options for Improving Diabetes Care

  • California SB 64 passed in 1999 mandated insurance coverage for diabetes supplies and outpatient education including medical nutrition therapy.
  • In 1996, Maine's legislature passed Public Law 592 requiring all health insurance policies in Maine to cover ambulatory diabetes education and followup programs.
  • Recognizing the devastating effects of this disease without a comprehensive approach to treatment, the Florida legislature passed legislation in 1996 that requires all insurers to provide coverage for all medically appropriate equipment and supplies in addition to diabetes outpatient self-management training and educational services used to treat diabetes.
  • California AB 942, enacted in October 2003, allows non-licensed school personnel to administer glucagon and also allows students with diabetes to test their blood glucose levels in the classroom and self-manage their disease anywhere on school grounds or at school sponsored events and field trips.
  • A number of States have passed authorizing legislation for Medicaid disease management programs, many of them aimed at diabetes. Examples of recent State legislation include: Delaware 2003 House Joint Resolution 10; Illinois 2003 SB 0064; Iowa 2003 House File 619; New Mexico 2003 SB 0338; Texas 2003 HB 727 and 2003 HB 1735.

As part of its DPCP, the State of Michigan has set up a statewide network aimed at ensuring comprehensive diabetes management.

The program, established as part of the Michigan Department of Community Health, Division of Chronic Disease and Injury Control, gained more resources in 1994 after receiving a CDC comprehensive grant and funds from the new State tobacco tax revenues. The State's Upper Peninsula region staff developed a model for working with health care providers on providing quality care and professional education aimed at improving diabetes care in the Finnish population. When the data showed that people served in the region had better outcomes, DPCP established six regional Diabetes Outreach Networks (DONs) statewide. Michigan's DON Diabetes Care Improvement Project was recognized as a Best Practice Initiative in 2002 by the Assistant Secretary for Health at the U.S. Department of Health and Human Services.

Michigan Diabetes Statistics

  • 707,200 adults and 6,200 children are diagnosed with diabetes in Michigan.
  • Diabetes related medical care costs Michigan almost $6 billion per year.
  • Sixty percent of direct costs were due to hospitalization.
  • An additional cost of $3.5 billion is attributable to lost productivity from premature death, disability, and illness.
  • Much of the indirect cost was related to complications of blindness and amputation.

Each DON in Michigan develops collaborative partnerships with health care delivery agencies, sponsoring and providing professional education, and coordinating and developing diabetes resources within their service region. Such collaboration of diabetes care resources is aimed at increasing awareness and ensuring that persons with diabetes and at risk for diabetes are identified and receive ongoing diabetes care and education. While the regional networks have some efforts that are unique to their area, much work is done on a statewide basis. The entire staff meets three times a year and holds conference calls on a monthly basis to coordinate efforts and develop programs.

Results from the Michigan DON demonstrate that working with health care agencies and providers through a statewide Diabetes Care Improvement Project can result in improved outcomes for persons with diabetes. Trends in follow-up data from fiscal year 1996-2001 show a significant increase in the number of persons with diabetes receiving important tests. Individualized data analysis from the regional DONs also shows a positive downward trend in the levels of HbA1c, which is associated with significantly reduced risk of complications. The program has demonstrated local reductions in diabetes-related hospitalizations, amputations, and mortality. The program began seeing these results relatively soon after implementation and has begun to close the gap between Michigan's diabetes averages and the national average.

"Simple lifestyle modifications such as healthy eating, moderate exercise, and weight control have conclusively been shown to prevent Type 2 diabetes by up to 60 percent. These solutions are low-tech and low cost, and yet they produce a high impact."

— Dr. Kimberlydawn Wisdom, Michigan Surgeon General

Michigan's Diabetes Policy Advisory Council works with DON directors and provides an opportunity for sharing information, best practices, and networking. In an effort to increase awareness and gain more support, regional directors meet regularly with area legislators to share information, identify gaps, and discuss how the legislature can help reduce the burden of diabetes. In addition, they meet with citizens and inform them about how they can seek legislative support.

Involvement by elected officials in diabetes related events has created momentum for the effort. Michigan was one of a group of States that participated in the Chronic Disease Academy sponsored by the CDC and hosted by the National Governors' Association. A team of agency directors, legislators, and advocacy groups attended this 3-day session and created a strategic plan for addressing chronic disease issues in the State. One of the ideas the State has implemented is a prevention caucus for legislators. Recently the group launched a challenge among State officials to adopt healthier habits. People in all branches of State government are now clocking their steps when they exercise and competing to be the most active. Even the Governor is wearing a pedometer. Involvement by elected leaders has attracted press attention and is raising public awareness.

The appointment of the State's first Surgeon General, Dr. Kimberlydawn Wisdom, has served to identify synergies between various efforts. In October 2003, Michigan presented its new Michigan Diabetes Strategic Plan. Developed by the Michigan Department of Community Health, the Michigan Diabetes Prevention and Control Program, and the Michigan Diabetes Strategic Plan Task Force and its Steering Committee, the plan addresses issues related to diabetes care and prevention. It also establishes a unified course of action among health care providers, public and private health officials, researchers, businesses, community groups, and people with diabetes to implement the most promising diabetes prevention and control strategies in the most cost-effective ways. Some highlights of the report include:

  • Expanding diabetes primary prevention activities.
  • Developing an ongoing public awareness campaign.
  • Developing a Statewide diabetes consumer advisory group.
  • Reducing diabetes-related health disparities among minority populations.
  • Providing quality diabetes pregnancy-related care and education to women.

Dr. Wisdom and U.S. Surgeon General Dr. Richard Carmona recently announced the involvement of Flint, Michigan in the DDI. In Michigan, the DDI will concentrate on the undiagnosed populations with a paper risk assessment test that can be followed up by a blood test and further treatment as necessary. Materials for the paper assessment are available through a variety of community channels such as social services, faith-based establishments, retail outlets, and fraternal organizations.


The State's DPCP has identified diabetes as a serious public health problem (Missouri Department of Health and Senior Services, 2002). Citing studies showing that interventions can prevent or delay diabetes complications, the State's DPCP has led the effort to implement the Chronic Care Model.

The department has collaborated with federally qualified health centers (FQHCs) and one National Health Service Corp site in HRSA's Health Disparities Collaborative for diabetes. Participating clinics were chosen strategically in an effort to align disease impact with a service provider who was ready and willing to work on the project. Each center implemented the Chronic Care Model in one or more clinics, forming teams of diabetes-related health care specialists. Each center established an initial registry of patients with diabetes. Additional provider and/or site registries were added as the year progressed. The electronic registries were used to monitor indicators of health behavior, health status, and services received. Monthly summary registry reports were sent to the State's DPCP, where the data were aggregated. The State's DPCP provided FQHCs with financial support, a local learning session, technical assistance on registry development, maintenance, health system redesign, monthly reports, and evaluation skills.

From June 2000 to May 2003, preliminary results indicated health centers significantly improved 12 of 16 diabetes-related care measures, including increases in the prevalence of at least two HbA1c tests at least 3 months apart (an increase of 15 percent), dilated eye exams (190 percent), foot exams (47 percent), influenza vaccinations (76 percent), and whether the patient set self-management goals (37 percent). Future efforts will focus on maintaining these improvements and extending Collaborative activities to other health care sites.

The DPCP has tapped other resources by working closely with the State's cardiovascular disease program and MissouriPRO, which has a contract from CMS to manage quality improvement on behalf of beneficiaries. MissouriPRO helped lead the training and implementation process for expanding the Collaborative to include 10 additional health providers. DPCP sees this partnership as a strategic alignment, expecting changes by CMS providers ultimately to have an impact on the rest of the State.

North Carolina

North Carolina's DPCP initiated a number of diabetes initiatives including a unique community-based program, Project DIRECT, that targets diabetes prevention and care efforts in the African-American community. Using a comprehensive approach, Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) encouraged exercise and improved nutrition, promoted awareness of diabetes, and increased screening for diabetes (CDC, 2003d).

Early on, the DPCP pulled together a statewide diabetes advisory council that included all stakeholders. The group became active in advocacy and policy issues. Their support was crucial in helping secure matching funds from the State legislature that allowed them to gain more resources from CDC as a basic implementation program. In 1996, members of the council successfully pushed legislation mandating that insurance cover diabetes education and testing strips. The most recent legislative action was the 2002 Care for School Children with Diabetes Act. At the time of passage in 2002 only three States had this kind of legislation for children in the public school system. The law ensures that the needs of students are addressed through an individualized diabetes care plan that includes provisions for snacks, testing, and assistance from an adult. The advisory council was very active in getting the bill passed.

North Carolina has reached 91 percent of its diabetes goals in the last 4 years, seeing increases in foot exams, eye exams, flu shots and HbA1c tests. The State has also met its goals in improvement among minority groups. The DPCP has begun working with the State QIO to examine Medicaid reimbursement claims for diabetes care, especially information on children.

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Selected Local Quality Improvement Efforts

In addition to national, Federal, and State quality improvement approaches, there are also local efforts to improve diabetes care quality. Local quality improvement initiatives are a crucial part of overall efforts because they are closer to and have more direct contact with providers and local health systems. Quality improvement programs and models, such as the Breakthrough Collaboratives or the Plan-Do-Study-Act model (discussed further in Module 5: Improvement), are best implemented at the local level. Yet, State-level support is critical to local efforts because payment structures, as well as the legal and regulatory structure of the health care market, are largely a State responsibility.

There are any number of local quality improvement initiatives that exist for diabetes, too many to list here. In addition to the Health Disparities Collaboratives (which involve the Federal, State, and local levels), two additional examples of local diabetes projects are included as illustrations of the links between national, Federal, State, and local contexts:

  • The St. Louis Diabetes Coalition is a voluntary network of health plans, provider groups, and other community organizations and companies that are working together to improve diabetes awareness, education and adherence to standards of care in the St. Louis area. The Coalition has worked together on a number of initiatives, including its Diabetes Screening and Treatment Guidelines. The treatment guidelines were endorsed by all of the major health plans in the St. Louis region, giving providers a single source for diabetes guidelines acceptable to all major payers. The Missouri Department of Health and Senior Services worked alongside the Coalition members to distribute the guidelines to more than 5,000 physicians in St. Louis and other parts of Missouri. More information about this and other the St. Louis Diabetes Coalition initiatives is available at
  • The Niagara Health Quality Coalition (NHQC) is a local organization of employers, providers, physicians and insurers in western New York dedicated to working together to achieve quality, affordable health care. NHQC is affiliated with the Buffalo Niagara Partnership, the largest employer organization in the Niagara area representing 3,300 firms with more than 200,000 employees. Stating that data are national but change is local, the NHQC provides links to both State and national data that can help local organizations, companies, and individuals become informed about the quality performance of various health care sectors. The NHQC's Web site,, links to hospital, health plan, physician, and long term-care quality data. The site also has links to clinical care guidelines for diabetes that were developed by the State diabetes coalition.

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Summary and Synthesis

The breadth of diabetes quality improvement activities both nationally and across the States provides State leaders with a variety of proven experiences, useful resources, lessons learned, and best practices for enhancing initiatives and partnerships in their own States. State programs have been successful in making inroads in diabetes prevention and quality improvement.

Yet, there is still much that can be done. Despite the efforts of States, national organizations, the Federal Government and a host of local and community efforts, there is still room for improvement. Diabetes rates continue to rise, substantial gaps in care for diabetes exist, preventable complications occur all too frequently, and the Nation is paying the price in higher health care costs and lower productivity and quality of life.

State leaders may also wonder which quality improvement strategies are the most promising approaches to achieving real improvements in diabetes care quality. While this question cannot be answered conclusively for the public policy arena, a recent research analysis of diabetes quality improvement strategies in clinical settings provides some evidence for prioritizing certain approaches. A systematic review of the literature on clinical diabetes quality improvement strategies found that provider education (i.e., meetings or conferences, outreach visits, and distribution of educational materials) and disease management were the most effective strategies in achieving significant improvements in patient HbA1c levels. However, the study also found multiple quality improvement interventions achieved more significant improvements in HbA1c levels and provider adherence to clinical guidelines than single interventions (Shojania, McDonald, Wachter, et al., 2004).


Before embarking on any particular public policy approach, however, State leaders will need to assess what is already being done to address diabetes care quality in their State. Talking with DPCP officials in the State health department, Medicaid directors, State employee benefit officials, State and community stakeholder group leaders, provider associations and professional societies can help State leaders assess what is already underway in the State, which efforts have been most successful and where additional efforts are needed. The State Diabetes Quality Improvement (QI) Inventory, presented in Table 4.2, is designed to assist State leaders in assessing the range of diabetes programming and determining the appropriate stage of development of an activity.

Based on this inventory, State leaders are ready to move to the next stage in the quality improvement process — actually developing a quality improvement strategy for a State. The next module of the Resource Guide is designed to assist State leaders with planning and implementing diabetes quality improvement action strategies by using information from previous modules in applying the PDSA model of quality improvement to the public policy setting. Module 5: Improvement also discusses important components of evaluation plans for State efforts.

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Associated Appendixes for Use With This Module

Appendix G: Index of Diabetes Quality Improvement Initiatives

Appendix G provides brief descriptions and links to further information for a variety of national and federal diabetes quality improvement initiatives. State leaders may want to review and consider these programs as models or resources for State action.

Appendix H: CDC and State Funding for DPCP, by State, 2003-2004

Appendix H shows the funding provided by the CDC to each State for the DPCP and each State's contribution. State contributions are shown by "general funds" and "in-kind" resources.

Page last reviewed August 2008
Internet Citation: Module 4: Action - Learning From Activities Underway (continued, 3): Diabetes Care Quality Improvement: A Resource Guide for State Action. August 2008. Agency for Healthcare Research and Quality, Rockville, MD.