Blueprint for Health and 2 more...less...

Blueprint for Health

Blueprint (SISC)

Statewide average % for Diabetes in Poor Control


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Notes on Methodology

The statewide average percentage of the Diabetes in Poor Control performance measure was generated by Onpoint Health Data, the statewide administrator of the All-Payer Claims Dataset. Onpoint linked claims in the APCD to clinical records stored by Capitol Health Associates in the Clinical Registry. Onpoint updated this measure every six months, accounting for the next 6 month time period. The statewide average percentage of the Diabetes in Poor Control performance measure was listed in every Health Service Area Adult profile, which can be found here ( The statewide average percentage of the Diabetes in Poor Control performance measure relies on data from the state’s Clinical Registry and therefore is influenced when practices interrupt their data feed to the Clinical Registry. The outcomes described here are estimated using data only from individuals for whom claims data could be linked with valid Clinical Registry data. This non-random sampling variability is not accounted for in the measure.

  • The local Blueprint Transformation Network, which includes: QI Facilitators, Community Health Team leaders, and Program Managers
  • Staff at Blueprint Patient-Centered Medical Home
  • Onpoint Health Analytics  
Story Behind the Curve

The Diabetes in Poor Control (i.e., Hemoglobin A1c>9%) measure is the third of 4 key indicators of quality health care. This measure assesses the percentage of continuously enrolled members with diabetes, ages 18–75 years, whose last recorded hemoglobin A1c test in the Clinical Registry was in poor control (>9%). This is a mixed methods measure relying both on claims and clinical data.

The Blueprint includes performance-based payments to encourage providers to participate in population and community health improvement initiatives with the goal of greater collaboration. These are key indicators that are in alignment with the All Payer Model core quality measures. Improvements in these areas are indicative of an evolving and improving system of care.

The trend line above suggests an opportunity for improvement given that the data is not moving in the right direction. The Blueprint implemented the pay for performance model on this measure in July 2015. This measure was chosen for payment because it reflected a priority of the provider network (ACO) in Vermont, it could be generated at the Health Service Area level using Vermont’s centralized data source without any need for additional data collection or reporting by providers, it was tied to prevalent underlying health concerns involving complex medical and social determinants, and it could be improved through better coordination, outreach, and transitions between medical and non-medical providers. Along with the ACO, VDH, and other statewide partners, the Blueprint held a 10-month Learning Collaborative in 2018-2019 to help practices improve diabetes care.

Across the network, practices are starting to implement concrete workflows to address diabetes management. For example, in Morrisville community in October 2019, both Stowe Family Practice and Morrisville Family Health Care planned the process to enhance their diabetic workflow, follow-up, and self-management assessment needs. In addition to supporting individuals with diabetes, those practices are now running registry reports for those identified as pre-diabetic based on preestablished criteria and reaching out to this group with information about the diabetes prevention self-management classes. Finally, they have incorporated improved data management and follow-up in a new electronic tracking system called ENLI with the goal of closely monitoring evidence-based follow-up care and self-management needs.

The community health team staff will assess and track the effectiveness of the outreach by performing in-depth chart reviews and ensuing notification of follow-up appointments and referrals.

Last updated:  03/02/2020


  • Continue as a performance payment measure
  • Support dissemination and use of the VDH toolkit on Diabetes care
  • Deploy QI Facilitators to practices interested in working on QI for diabetes care
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy