Official Stars Rules
This gap will be considered Out of Control or OOC and will not close even if it is the most recent value of the calendar year when the value is > 9%
What is the Diabetes Care - Blood Sugar Controlled Gap
Your member has a gap for A1C (missing) and states they have an appointment with their PCP in 5 months. What would be the BEST PRACTICE to address this gap?
Order an A1C at a local lab now for the member to get completed or offer an in home Everlywell kit/in home lab draw (if available) to member
In the candidates tab, if the member is Identified as “THIS” for the program match, you should be considering strongly referring and directing scheduling this member for that specialty program. As long as you feel this status still applies during your visit.
GOOD
When the member states my PCP checks my urine I don’t need that test (referring to the uACR), but in review you see the PCP has never actually ordered one of these before and is just checking routine UA’s, what should be your response?
Educating the member that the uACR is not included in a routine urinalysis and is a separate urine test. This test is very important to ensure we are detecting early signs of kidney damage in the setting of diabetes that may not show up on kidney blood work. We have the test for free as an in home test they can receive in the mail and you can mail them one. It is easy and we will send them the results as well as their PCP
This gap requires two lab values in the current calendar year to be satisfied
What is the Diabetes Care- Kidney Disease Health or KED GAP?
Your member is 8 days to GNA and they are considered “Unsatisfied” for Their Medication Adherence for Cholesterol (Statins) gap. You find out they have slowly been a week or so late picking their prescription up due to schedule and location of their pharmacy. What is the best action to take?
Offer and get member enrolled in CVS Mail order pharmacy as well as MOT so they get the medication on time every month, as well has have a safety net if they don’t have a prescription on file
If your member isn’t initially sure about a specialty program what is one thing you could refer to tailor your conversation to them?
Personalized Referral Hook
Your member tells you they are afraid of a colonoscopy. They have no current symptoms or concerns and no family history of colon cancer. What are some ways to approach this?
Offer a FIT to complete at home and then discuss with PCP further at next appointment the benefits and risks of a Colonoscopy. This will at least provide a screening and rule out any immediate colon cancer concerns.
This gap has 4 different ways or tests to satisfy the gap. Name them and their time span to satisfy the gap
What is The CRC gap or Colorectal Cancer Screening Gap.
You can close for the calendar year with a FIT done in the current calendar year, for 3 years with a Cologuard, 5 years with a flexible Sigmoidoscopy or 10 years with a colonoscopy
It is January and you see your member has an “Unofficial” STARS gap for the Diabetes Care - Eye Exam. Next you find your member has not had their diabetic eye exam for 2 years now. What should be your approach?
Recognize this gap is likely unofficial due to it being the beginning of the year and will likely become official with one more diabetic claim (could be your visit today!) So Offering an in home exam (if available) OR ordering and scheduling their eye exam with them today would be the best action
Your member has several claims for a systolic b/p >140 and diastolic b/p > 90. In your visit you also record a b/p of 145/99 being the lowest reading after 3 readings. What would you do for this member?
Navigate to the Candidates tab, ensure this member is not “Blocked” for a Hypertension Disease Management referral. Review how the program works and educate the member on why this program is beneficial and will help them. Finally refer and schedule their appointment with the HTN Team
Your member states they PCP stopped their Statin due to a low LDL and they were trying to eliminate unnecessary medications from their list. However you member is diabetic with an A1C of 7.9%. What should you do?
Educate your member that when someone is diabetic, the number is not necessary the target to treat cholesterol. The goal is to actually reduce inflammation, allow for less cholesterol overall when the lumen or vessels are smaller than average in the setting of diabetes and reduce risk of heart attack, stroke and other cardiovascular events by 20-40%. Even considering 3 times a week is better than nothing. The benefits outweigh the risks of medication burden, this would not be one to eliminate.
This member had 2 fills of Lisinopril this year with a pharmacy claim. They saw their PCP last week who discontinued this medication and started them on Valsartan instead. The MAGII Gap For RAS Antagonist will remain satisfied as long as the member continues to take the Valsartan compliantly through the rest of the calendar year. TRUE OR FALSE?
TRUE - It is a “Class specific” Gap, so as long as the claims remain compliant through the year for any medication in this class (that includes ACE’s and ARBS’) The gap will remain satisfied.
Your member is hesitant and very much not convinced that a mammogram is necessary. She is 66 and has never had one. She reports no family history of Breast Cancer and no concerns or symptoms currently. What is your next best action?
Educate this member about how Mammograms are preventative, designed ideally to be done when there are no symptoms, problems or family history as they will detect early cancer saving lives. Remind the member that a mammogram saves 21 lives for women between the ages of 60-69 for every 10,000 screened. Then assist the member in scheduling her test so she doesn’t have to and make it easier and most likely more successful.
If your member agrees to a specialty program and the functionality is present, what should you do to ensure highest success to that appointment taking place?
Direct Schedule
Your member refuses a Diabetic eye exam due to being “legally Blind” and doesn’t see the benefit in this. What should you do?
First, legally blind doesn’t mean “total Darkness”; most people with legal blindness still retain partial, high valuable vision. This test can help to protect a patient’s comfort and remaining independence by serving the following purposes:
Preserves residual functioning vision
Prevents severe ocular pain
Prevents structural eye damage
Actually helps to guide diabetes management. The window to your blood vessels is the only place in the body where a doctor can directly see living blood vessels. This helps them to judge if your medication regimen is effective enough.