MAKE PERFORMANCE REVIEWS FOR ADVANCED PRACTICE PROVIDERS MUTUALLY BENEFICIAL

Supervising advanced practice providers (APPs) can have many benefits, but the associated quality reviews can seem onerous and not useful. State regulations and organizational policies differ, but most require physicians to review the quality of care APPs provide.

Here are some ways to approach this process with a purpose beyond just compliance.

• Consider it a mentoring opportunity. Mentoring reframes it as a positive, voluntary, and mutually beneficial relationship.

• Schedule time each month. Blocking off time on both parties’ calendars provides a deadline to keep the review process on track and creates common expectations for discussing clinical care and professional development.

• Use a standard form. Having a ready template (electronic or hard copy) makes documentation of the review process quicker and easier.

• Involve the APP. Have the APP suggest patients for review based on interesting presentations or challenging circumstances.

• Capture “real-time” interactions. When you and the APP are involved in a shared patient encounter, use the opportunity to review the care and documentation.

• Consider other benefits. The review process can enhance your professional relationship with the APP, instill confidence that patients are receiving high-quality care, and mitigate the risk of “negligent supervision” concerns.

MANAGE REQUESTS FOR CONTINUOUS GLUCOSE MONITORING

As the number of new insulin management systems and wearable health technologies increases, family physicians may field more requests for continuous glucose monitoring (CGM). Managing these requests can be challenging.

As part of a CGM pilot project, we queried our electronic health record (EHR) to reveal that we had 462 patients with diabetes. Of those, 55 had an A1C greater than 9% and were deemed good candidates for CGM. Physicians discussed the CGM device with these patients and started prescribing supplies. Within four months, seven patients were approved for CGM. Two of them had Medicare as their primary insurance, and the other five had Medicaid. (No private insurer approved the devices.)

Here’s what we have learned so far about the process for getting patients approved for CGM:

• Eligibility differs for patients with type 1 versus type 2 diabetes. Patients with newly diagnosed type 1 diabetes got approved quickly. Patients with type 2 diabetes got approved only if they were using at least two types of insulin. The requirement that patients check their blood sugar at least four times daily was removed by Medicare in 2021. We were not able to obtain CGM approval for patients on long-acting insulin with oral antidiabetic drugs.

• Prior authorization is cumbersome but can be streamlined. After prescribing CGM supplies, we started receiving faxes with prior authorization requests from various companies that work with pharmacies and payers to coordinate fulfillment. Navigating durable medical equipment (DME) suppliers was the most challenging part, but we found several ways to streamline it. Standardize documentation of the medical need for CGM to make sure all the requirements are captured. Call the supplier after the first fax. Track which pharmacies work with each supplier to find out where to send patient information. Get familiar with their online portals to effectively manage the process. Use a dedicated fax number in your practice for authorizations. And add sticky notes or an addendum in the patient’s chart so that clinic staff or colleagues can track progress.

• A team effort is key. Determine which team members can help with each part of the process, from generating a list of eligible patients to following up on requests as needed.

Now that a few of our patients have obtained CGM devices, we are focusing on data interpretation, data sharing, and troubleshooting the devices. Our next goal is to compare glycemic control between our patients using CGM and those using the conventional fingerstick method.

For more on CGM, see the AAFP TIPS CGM module and the FPM article “Implementing Continuous Glucose Monitoring in Clinical Practice.”