Search

How to Start a Professional CGM Program

GettyImages-1370674740_700x400
Looking to start a CGM program in your practice? Learn from these experts.

From the Personal Continuous Glucose Monitoring Implementation Playbook from ADCES and AphA. Contributors include: Patricia L. Scalzo, MSN, NP, RN, CDCES, Kelly A. Brock, PharmD, RPh and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES. This effort was supported by Dexcom & Abbott.

Looking to start a professional CGM program in your practice? Our experts have outlined 11 key steps to get you started and set you up for success.

Identify feasibility of the program through evaluation of your population and of support structures within your practice setting. Begin by outlining benefits to the people with diabetes, providers and practice.

  • Are you doing all you can to optimize your patients’ diabetes  management?
  • How could personal CGM benefit your patient population?
  • Would your patient population be amenable to personal CGM?
  • Are the providers in your practice resourced appropriately to support a personal CGM program?
  • What does your practice hope to gain by implementing this program?
  • How could a personal CGM program add value to your patients, providers and practice?
  • Could it help improve the diabetes care provided in your practice?
  • Could it help to improve the diabetes metrics in your practice? Once this genuine need is clearly identified, you will know that you are headed in the right direction.

    CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE 
    • Categorize your diabetes population by types of diabetes therapies that they utilize.
    • What percent uses multiple daily insulin injections or insulin pumps?
    • What percent uses basal insulin plus orals or other injectables?
    • What percent uses oral agents that may cause hypoglycemia, such as sulfonylureas, etc.?
    • How many are currently utilizing personal CGM devices?
    • Meet with the members of your healthcare team to identify pros and cons of using personal CGM to manage people with diabetes in your practice See Worksheet 1
    • Meet with all important stakeholders (e.g., leadership team ,support staff) to identify any concerns they have and obtain their buy-in
    • Identify outcomes of a successful Personal CGM Program, to people with diabetes, the providers and to the practice See Worksheet 2 

Finding the right composition of the team is vital, and depending on your practice, you will need to decide who should be included on the team.

Enthusiastic and well-qualified team members will ensure a successful launch of the program. In this phase you will need to identify who will be on the team and what their roles will be.

  • A diabetes care and education specialist (DCES) is valuable to the team if you have one on your staff. The diabetes care and education specialist can help the individual understand how various lifestyle factors and self-care behaviors affect their diabetes management and possess the knowledge base to offer thorough training on the CGM device to the person with diabetes.
  • A pharmacist can provide medication-related expertise, which can add value to a personal CGM program because they can work with the patient and the physician to make adjustments to the treatment plan based on CGM results.
  • A person that is knowledgeable in downloading CGM devices will be vital to the team.
  • The CGM device company representative may be part of your team to assist with device training and follow-up.

    CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE
    • Identify the members of your team See Worksheet 3
    • Define roles and responsibilities of each team member. See Worksheet 4 & Worksheet 5
    • Meet as a team regularly
    • Seek ongoing feedback from all involved parties 

Adding a Personal CGM Program to your practice will require changes to your current workflow. You have already identified the roles of your team members, so you are aware of what new responsibilities they will be taking on. It is helpful to define the Personal CGM process from start to finish so you have a clear understanding of all steps. See Worksheet 6

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE  

  • Seek input from all team members regarding the design of the workflow 
  • Define the workflow of an in-person visit from beginning to end 
    • Include specifics about patient selection, use of the device, providing education to patient, diagnosis/coding/billing, documentation, downloading and interpreting results 
    • The ADCES Identify-Configure-Collaborate framework provides a standardized 3-step process for integrating diabetes technology into your practice33. See Worksheet 7 
  • Define the workflow of a remote monitoring visit from beginning to end 
  • Update existing protocols or create new ones to accommodate this new workflow in daily practice 
  • Plan for enhanced staffing levels as you roll out the new program 
  • Identify necessary resources that will support the new workflow 
  • Solicit staff feedback every step of the way 
  • Plan for ongoing scheduled evaluation of workflow and adjust as needed 
  • Determine what data you will want to collect ongoing 

Commercial insurance and Medicaid plans vary in regard to amount of coverage for personal CGM devices and their ongoing supplies. Medicare will cover personal CGM if the following criteria are met: 

  • Have a diagnosis of diabetes, either type 1 or type 2 
  • Use a home blood glucose monitor (BGM) and conduct four or more daily BGM tests
  • Treated with insulin with multiple daily injections or a continuous subcutaneous insulin infusion (CSII) pump.
  • Require frequent adjustments of the insulin treatment regimen, based on therapeutic CGM test results.

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE 

    • Seek input from all team members regarding the design of the workflow
    • Define the workflow of an in-person visit from beginning to end 

Defining the documentation and billing process before you begin will help ensure that all potential roadblocks are anticipated, identified and addressed. Educate staff on the billing codes to utilize for Personal CGM. See Worksheet 8 

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE  

  • Identify the team member to be accountable for coordination of insurance benefits and requirements
  • Provide an in-service for staff on coding, billing and documentation requirements for Personal CGM 
  • Provide an in-service for staff about CGM remote monitoring visits that includes documentation and billing requirements  
  • Identify team member(s) to perform ongoing documentation, coding and billing audits of individuals in the program 

Staff will need to be trained on the personal CGM program being offered in your practice. Training should cover an overview of the workflow, including patient selection, use of the device, providing education to patient, diagnosis/coding/billing, documentation34, download and interpretation of results. 

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE  

  • Develop protocol that identifies characteristics of individuals that would most likely benefit from Personal CGM. See Worksheet 9.
  • Set up vendor training sessions for all involved staff to learn about the different personal CGM devices and how to download information
  • Provide resources for staff about the different routes to obtain Personal CGM (how to pick up the product at pharmacy or obtain from DME supplier)
  • Develop staff competencies that are role specific and identify a process to review and document their skills on an ongoing basis
  • Set up provider training on program workflow and protocols, diagnosis/coding/billing, interpretation and documentation of downloaded information
  • Plan for annual training refresher 

Ensure that all team members are aware of their roles and responsibilities. Proper staff preparation will make sure that the team is on board with the program and motivated to put in their best effort to help make it a success. Remember to start process evaluation as soon as the implementation stage kicks off.

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE

  • Host a program launch kick-off event to review roles/responsibilities and provide a program overview
  • Identify staff “superusers” who can serve as resources to others
  • Have vendor and IT available during implementation 
  • Make device procedure reference materials and troubleshooting guides widely available
  • Provide a forum for staff to provide feedback and suggestions 

The Personal CGM Program will anticipate an upfront learning curve for the person with diabetes. It is vitally important to provide initial and ongoing education about their personal CGM device. 

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE 

  • Develop a handout for the person with diabetes that discusses how to get the most out of their Personal CGM. The power of data can help the person feel more in control of their diabetes and can facilitate a more collaborative approach with the healthcare team. See Worksheet 11
  • Provide initial training including a detailed education plan for the patient about their personal CGM device and ongoing training to help them maximize the use of their device. See Worksheet 12 
  • Identify procedure to provide ongoing support for person using personal CGM 

You are now ready to try out your new program! All the pieces should be in place. Solicit feedback and ideas from staff and patients throughout the implementation process. Start tracking success measures at program initiation. 

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE 

  • Walk through the process from start to finish
  • Provide on-site technical and product support resources to staff during launch
  • Perform frequent check-ins with staff at this beginning phase of the program implementation
  • Schedule a weekly staff meeting to discuss how things are going 
  • Start collecting any clinical and financial data that you will want to analyze on an ongoing basis 

Program evaluation is an ongoing process. Be thoughtful and quickly responsive to suggestions/ideas/feedback. Continually refer to the metrics of program success that you have identified. Celebrate once you are meeting these success points. If you are not meeting them, determine what the obstacles and challenges are and how you can address or avoid these barriers moving forward. Practice continuous quality improvement. 

CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE 

  • Gather staff feedback on a consistent basis
  • Survey the persons with diabetes that are being served by this program regarding their satisfaction 
  • Analyze and evaluate the clinical and financial data that you have collected
  • Compare diabetes outcomes post-Personal CGM Program to pre-program outcomes
  • If you are not meeting success metrics, re-evaluate your program process and amend as necessary
  • If you are meeting success metrics, disseminate the results widely
  • Meet with the entire team to determine next steps. Is program the right size? Does it have the right composition of staff? Is there reasonable access to the program? 

Planning for the future of your Personal CGM program is a crucial component of a successful program. 

  • What are the next steps for your program?
  • Do you want to establish a satellite location?
  • Do you want to start working with patients remotely?
  • Do you want to offer a personal CGM support group or annual group education class geared to people who use personal CGM devices?
  • Do you want to share your program experience and lessons learned with other care teams?
    CHECKLIST OF ITEMS TO ACCOMPLISH DURING THIS PHASE
    • Hold a meeting with the entire team to discuss future goals for the program
    • Explore feasibility of goals
    • Market the program to others that may wish to refer to your program 
References: 1 Chehregosha, H, Khamseh, ME, Malek, M, et al. A View Beyond HbA1c: Role of Continuous Glucose Monitoring. Diabetes Therapy. 2019;10, 853–863 2 Sagar R, Abbas A, Ajjan R. Glucose monitoring in diabetes: from clinical studies to real-world practice. Practical Diabetes. 2019;36. 57-62. 10.1002/pdi.2215. 3 Ajjan R, Slattery D, Wright E. Continuous Glucose Monitoring: A Brief Review for Primary Care Practitioners. Advances in Therapy. 2019;36:579-596 4 Aleppo G, Laffel LM, Ahmann AJ, et al. A Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes, Journal of the Endocrine Society, Volume 1, Issue 12, 1 December 2017, Pages 1445–1460, https://doi.org/10.1210/js.2017-00388 5 Kudva YC, Ahmann AJ, Bergenstal RM, et al. Approach to Using Trend Arrows in the FreeStyle Libre Flash Glucose Monitoring Systems in Adults, Journal of the Endocrine Society, Volume 2, Issue 12, December 2018, Pages 1320–1337, https://doi. org/10.1210/js.2018-00294 6 Šoupal J, Petruželková L, Grunberger G, et al. Glycemic Outcomes in Adults With T1D Are Impacted More by Continuous Glucose Monitoring Than by Insulin Delivery Method: 3 Years of Follow-Up From the COMISAIR Study. Diabetes Care. 2020 Jan;43(1):37-43. doi: 10.2337/dc19-0888. Epub 2019 Sep 17. 7 Mulinacci G, Alonso T, Snell-Bergeon JK, Shah VN. Glycemic Outcomes with Early Initiation of Continuous Glucose Monitoring System in Recently Diagnosed Patients with Type 1 Diabetes. Diabetes Technology & Therapeutics. 2018;21. 10.1089/ dia.2018.0257. 8 Peters, AL. The Evidence Base for Continuous Glucose Monitoring. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 3-7. doi: 10.2337/db20181-3 9 American Association of Diabetes Educators Practice Paper. The Diabetes Educator Role in Continuous Glucose Monitoring. 2018. Updated Dec2019; https://www.danatech.org/media/ntgjf2di/diabetescareeducationspecialistrolecgm_aug20.pdf 10 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 11 Peters AL, Ahmann AJ, Battelino T, et al.: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101:3922–3937 12 Garber AJ, Handelsman Y, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocrine Practice 2020, 26 (1): 107-139 13 Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40:1631–40 14 Aleppo G, Webb K. Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation. Journal of Diabetes Science & Technology. 2018; https://doi.org/10.1177%2F1932296818813581 15 Petrie JR, Peters AL, Bergenstal RM, et al. Improving the clinical value and utility of CGM systems: Issues and Recommendations: A joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. Oct 2017, dci170043; DOI: 10.2337/dci17-0043 16 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 17 U.S. Centers for Medicare & Medicaid Services. Medicares Coverage of Diabetes Supplies, Services & Prevention Programs. Publication # 11022. Revised 12/01/2019 18 Kompala T, Neinstein A. A New Era: Increasing Continuous Glucose Monitoring Use in Type 2 Diabetes. American Journal Managed Care. 2019 Mar;25(4 Spec No.):SP123-SP126. 19 Welsh JB. Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes. Diabetes Technology & Therapeutics. Jun 2018.S2-42-S2-49.http://doi.org/10.1089/dia.2018.0100 20 Heinemann, L, Klonoff, D. C. An Opportunity to Increase the Benefit of CGM Usage: The Need to Train the Patients Adequately. Journal of Diabetes Science and Technology. 2019 https://doi.org/10.1177/1932296819895083 21 Longo, R, Sperling, S. Personal Versus Professional Continuous Glucose Monitoring: When to Use Which on Whom. Diabetes Spectrum. 2019;32. 183-193. 10.2337/ds18-0093 PART SIX: References Personal Continuous Glucose Monitoring Implementation Playbook 61 22 Tanenbaum ML, Adams RN, Lanning MS, et al. Using Cluster Analysis to Understand Clinician Readiness to Promote Continuous Glucose Monitoring Adoption. Journal of Diabetes Science & Technology. 2018;12(6):1108–1115 23 American Diabetes Association. Overcoming Therapeutic Inertia: Accelerating Diabetes Care for Life. American Diabetes Association Summit. Summary of Proceedings. 2019 24 Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2019;179(10):1376–1385. doi:10.1001/jamainternmed.2019.2396 25 Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges, and Opportunities. Diabetes Technol Ther. 2016 Feb 1; 18(Suppl 2): S2-3–S2-13. doi: 10.1089/dia.2015.0417 26 Smith MB, Albanese-O’Neill A, Macieira TGR, Yao Y, et al. Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review. Diabetes Technology & Therapeutics. Oct 2019.589-601.http://doi.org/10.1089/ dia.2019.0136 27 Johnson ML, Martens TW, Criego AB, Carlson AL, et al. Utilizing the Ambulatory Glucose Profile to Standardize and Implement Continuous Glucose Monitoring in Clinical Practice. Diabetes Technology & Therapeutics. Jun 2019.S2-17-S2-25.http://doi. org/10.1089/dia.2019.0034 28 Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40:1631–40 29 Battelino T, Danne T, Bergenstal RM, et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations from the International Consensus on Time in Range. Diabetes Care 2019;42:1593-1603. doi10.2337/dci19-0028. 30 Bergenstal, RM. Continuous Glucose Monitoring Data as an Adjunct to A1C. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 19-20. doi: 10.2337/db20181-3 31 Kruger DF, Edelman SV, Hinnen DA, Parkin CG. Reference Guide for Integrating Continuous Glucose Monitoring into Clinical Practice. The Diabetes Educator. 2019 Feb;45(1_suppl):3S-20S 32 Isaacs D, Cox C, Schwab K, et al. Technology Integration - The Role of the Diabetes Care and Education Specialist in Practice. The Diabetes Educator. 2020 Aug. 323-334. doi: 10.1177/0145721720935123 33 Greenwood DA, Howell F, Scher L, et al. A Framework for Optimizing Technology-Enabled Diabetes and Cardiometabolic Care and Education - The Role of the Diabetes Care and Education Specialist. The Diabetes Educator. 2020 Aug. 315-322. doi:10.1177/0145721720935125 34 Carlson AL, Mullen DM, Bergenstal RM. Clinical Use of Continuous Glucose Monitoring in Adults with Type 2 Diabetes. Diabetes Technology & Therapeutics. 2017;19:S4–11 35 Adolfsson P, Parkin CG, Thomas A, Krinelke LG. Selecting the Appropriate Continuous Glucose Monitoring System – a Practical Approach. European Endocrinology. 2018;14:24–29. 10.17925/EE.2018.14.1.24 36 Barnard-Kelly, KD, Polonsky, WH. Development of a Novel Tool to Support Engagement With Continuous Glucose Monitoring Systems and Optimize Outcomes. Journal of Diabetes Science and Technology, 2020;14(1), 151–154. https://doi. org/10.1177/1932296819848686

DISCLAIMERS:

This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or healthcare provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit diabeteseducator.org/Find.

ADCES and danatech curate product specifics and periodically review them for accuracy and relevance. As a result, the information may or may not be the most recent. We recommend visiting the manufacturer's website for the latest details if you have any questions.