Assessment #1: Diabetic Retinopathy: Assess members with diabetes for diabetic retinopathy with a non-mydriatic fundus camera. Provide members with diabetes the annual retinal assessment to meet HEDIS quality improvement measures. Provide both technical and professional interpretation and recommendation to the member's primary care provider (PCP) for any follow up care.

Assessment #2: Diabetic Peripheral Neuropathy: Assess members with diabetes for peripheral diabetic neuropathy through a non-invasive rapid sural nerve conduction device (DPNCheck). Refer members at high risk for foot ulcers for follow up care with either their primary care physician or podiatrist for preventive early interventions.

Assessment #3: Diabetic Nephropathy: Assess members with diabetes for diabetic nephropathy via a microalbuminuria test, albumin-to-creatinine ratio test (also known as the ACR test) or the urine albumin test. In addition, an estimated Glomerular Filtration Rate (eGFR) to assess renal function will also be obtained. Identify members with CKD to preserve filtration, monitor CKD progression and to facilitate patient-clinician communication.

Assessment #4: Peripheral Arterial Disease (PAD): Research shows that patients with Peripheral Arterial Disease (PAD) are four times more likely than the general population for risk of heart attack. Assess members to determine Ankle Brachial Index (ABI) and Pulse Volume Recording (PVR) with a non-invasive FDA cleared device. Identify members with cardiovascular disease with evidence of peripheral arterial disease for follow up care.

• Body Mass Index Measurement

• Cholesterol Controlled - LDL-C Assessment

• Comprehensive Diabetes Care - Blood Pressure Controlled (<140/90)

• Comprehensive Diabetes Care - Retinal Assessment

• Comprehensive Diabetes Care - HbA1c Poor Control (>9%)

• Comprehensive Diabetes Care - Nephropathy (Microalbumin Test)

• Review of Chronic Conditions for Hierarchical Condition Codes (HCC)

Primary care providers need to know as much as they can about their patients, especially those with diabetes. Monitoring patients with diabetes to slow disease progression, adhering to medication prescription regimen, monitoring laboratory tests that needs to be updated, facilitating necessary follow-up assessments, and achieving thorough diagnosis code documentation are but a few of the challenges facing primary care providers.

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