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Optimizing Care for Patients With Type 2 Diabetes and Heart FailureThe American Heart Association (AHA) and the Heart Failure Society of America (HFSA) report that between 9% and 22% of people withdiabetes have HF—four times higher than the general population.7 Similarly, between 25% and 40% of patients with HF have diabetes.8T2DM is a well-established risk factor for HF.9 As a result, physicians who manage patients with T2DM often encounter individualswith newly diagnosed HF. Results from a large study of diabetic patients free of cardiovascular disease showed that 14.1% of diabeticpatients had a new diagnosis of HF over 5.5 years of follow-up.10 The number of patients with T2DM who are at risk of developing HFis increasing, not only because the prevalence of T2DM is increasing, but also because people are being diagnosed with T2DM atyounger ages. People who develop diabetes earlier in life have less favorable cardiovascular profiles in middle and older age.1,11,12,13These trends underscore the need for appropriate management of patients with T2DM HF.Given the frequency with which T2DM and HF co-occur, it is not surprising that the ADA recognizes the importance of HF among peoplewith diabetes and that ADA practice guidelines include recommendations for treating patients with both conditions.14 Likewise, guidelinesfrom the American College of Cardiology (ACC) recognize T2DM as an important comorbidity among people with HF, and ACCguidelines also address how to care for patients with concurrent diabetes and HF.15 Despite the availability of practice guidelines fortreatment of patients with comorbid T2DM HF, persistent challenges associated with managing these patients are widely recognized.16That the survival rate of patients with T2DM HF is about half that of patients with HF alone17,18 suggests considerable room for improvementin how they are managed.The challenges associated with treating HF and other comorbid illnesses among people with T2DM have been explored in detail.19 Patientswith T2DM HF frequently have multiple health care “touch points” that may include regular interactions with a primary care clinician, anendocrinologist and a cardiologist. These clinicians may focus on different aspects of patient care, and patient management efforts—includingprescribing—may occur with little or no knowledge about actions recommended by other members of the patient’s care team.In addition to the challenges associated with lack of care coordination, office visits may be short, a constraint that makes visits incompatiblewith the large number of activities—health maintenance, screening, education and treatment activities—that must occur. Clinicians alsomust stay up to date with changing practice guidelines from multiple medical societies; must learn about and effectively incorporate newtreatments into routine patient care; must safely titrate and monitor numerous medications; and must overcome diverse challenges linked totheir practice environments. The ADA, AHA and ACC all advocate for efforts to improve care for patients with T2DM HF.20,21,22Against this backdrop, the National Committee for Quality Assurance sought expert input to explore strategies to drive improvements inthe quality of care for patients with T2DM HF. In June 2020, NCQA convened a diverse panel of clinicians—the Diabetes and HeartFailure Roundtable—for a discussion about the challenges of managing patients with T2DM HF. This report summarizes the discussion andrecommendations from that meeting.www.ncqa.org7

MethodsResponding to concerns raised by professional societies and other stakeholders about the challenges of managing patients withT2DM HF, NCQA organized the Diabetes and Heart Failure Roundtable, a one-day discussion to define optimal care for this patientpopulation, identify barriers that inhibit access to ideal care and develop potential short- and long-term strategies that may improve thequality of health care delivery for these patients.To ensure input from diverse clinical viewpoints, NCQA identified health professionals who represented a wide variety of disciplines andpatient care settings. Roundtable panelists offered expertise in cardiology, endocrinology, pharmacy, family medicine and nephrology.Their perspectives also drew from patient care experience in urban and rural settings, specialty clinics, community-based family practices,academic medical centers and community hospitals. Refer to Acknowledgments for a list of roundtable panelists, their specialties and theirinstitutional affiliations.The treatment landscape for patients with T2DM HF is complex. To ensure that roundtable panelists approached the conversation andmeeting objectives from the same vantage point, they were given a “patient entry point” as a discussion framework: a hypotheticalpatient with T2DM who presents to the primary care clinician (PCC) with a diagnosis of early symptomatic HF. Panelists were asked to1.) describe the “ideal” care for this patient; 2.) define barriers that inhibit access to or delivery of ideal care; and 3.) articulate short- andlong-term strategies to improve care delivery for patients with T2DM HF.Originally planned as an in-person meeting in Washington, DC, in April, the roundtable was held virtually in June because of the COVID-19pandemic. It was recorded, and this report is based on the meeting transcript and post-meeting discussion among NCQA staff.8www.ncqa.org

Optimizing Care for Patients With Type 2 Diabetes and Heart FailureIdeal Care Delivery for PatientsWith Diabetes and Heart FailureWhen presented with a hypothetical patient with T2DM who presents to the PCC with a new diagnosis of early HF, roundtable panelistswere first asked to envision a scenario in which factors that often hinder optimal care delivery—cost, access, geography, reimbursement—played no role in determining how the patient was evaluated and subsequently managed. They were then asked to articulate ideal carepathways for this patient.Panelists emphasized that nuances of a case ultimately determine how a patient should be evaluated and managed. The decision to refera patient to an endocrinologist or cardiologist is linked to a PCC’s comfort level managing patients with T2DM HF, whether specialists arereadily available for referral and factors related to the PCC’s practice setting. With regard to setting, integrated health systems often haveestablished pathways for accessing specialist care, while standalone PCC practices frequently rely on informal referral networks that arebuilt on personal relationships with specialists in their area.Added to these considerations are patient-level factors that contribute to whether, and to whom, PCCs refer patients for specialty care:potential financial penalties to patients for using out-of-network physicians and patients’ willingness and ability to follow recommendedcare plans. Despite these caveats and practical considerations, roundtable panelists spoke at length about circumstances that wouldfacilitate ideal care delivery for their T2DM HF patients.Table 1 summarizes key elements of their vision; details are provided in the sections below.TABLE 1: Elements of Ideal Care for Patients with Type 2 Diabetes and Newly Diagnosed Heart FailureComprehensive evaluation at presentationAccess to specialists if they are neededSeamless care coordination among primary care clinicians, specialists and patientsCo-location and availability of shared physical or virtual careIntegration of pharmacists into the care teamOptimal patient educationMaximized use of nonphysician health care professionalsAbility to leverage information from community-based resourcesAvailability of financial and other patient navigation supportsReturn to pg. 5www.ncqa.org9

Optimizing Care for Patients With Type 2 Diabetes and Heart FailureComprehensive Evaluation at PresentationPanelists agreed that ideal care for patients with T2DM HF begins with a comprehensive evaluation: a thorough patient history, a detailedmedication inventory, patient input on treatment goals and results of relevant recent assessments. With this information, appropriate testsshould be ordered and an evidence-based care plan that includes patient preferences and priorities should be defined.The care plan should not only reflect the patient’s physiologic needs regarding T2DM HF, but should also consider the impact of otherhealth conditions that may be present, as well as social determinants of health (SDOH) that may affect the patient’s ability or willingnessto embrace and adhere to a care plan. Panelists agreed that care planning should initially focus on improving symptoms as quickly aspossible, and focus on reducing morbidity and mortality once this has been achieved.Access to Specialists if They Are NeededThere was considerable discussion about the importance of access to specialist care, and general agreement that many factors—a PCC’sexperience and comfort level managing T2DM HF patients, geography and the availability of specialist care—play a role in determiningwhether such care is sought. Yet the panelists agreed that the ability of patients to access specialists with expertise in endocrinology andcardiology is a critically important aspect of ideal care for patients with T2DM HF. This is supported by research showing that amongMedicare beneficiaries with complex chronic conditions, access to specialist care in the previous year was associated with a 15.9%lower preventable hospitalization rate and a 16.6% lower mortality rate.23 In rural areas, access can be greatly facilitated by the ongoingevolution and roll-out of telehealth and similar technologies that break down long-standing barriers between patients and the specialiststhey need. A growing body of research has shown the benefits of these technologies for management of both T2DM and HF.24,25Seamless Care Coordination Among Primary Care Clinicians, Specialists and PatientsThe importance of care coordination for patients with T2DM HF was a central theme throughout the roundtable discussion. Panelistsemphasized that because these patients often have complex risk factor profiles and take multiple medications, there is a critical needfor all members of the care team to be aware of, and work toward together, attainable goals shared by the clinicians and the patient.Clearly defined roles and responsibilities about specific aspects of a patient’s care plan (e.g., glucose management, HF management,management of risk factors such as lipids and blood pressure) must be established. Studies of medically complex patients, including thosewith T2DM HF, indicate that investment in care coordination between primary care and specialists may improve patient experiences withcare coordination and ultimately have a positive impact on care and outcomes.26 Implicit in seamless care coordination is the ability of allmembers of the care team to access patient health information, including results of laboratory tests. The importance to care coordination ofinformation transfer, patient monitoring systems and tools that allow patients to connect with their doctors has been described.27Return to Table 1In rural areas, access can be greatly facilitated by the ongoing evolution and rollout of telehealth and similar technologies that break down long-standing barriersbetween patients and the specialists they need. A growing body of research hasshown the benefits of these technologies for management of both T2DM and HF.24,25

Co-location and Availability of Shared Physical or Virtual SpacesThe ability of all members of the care team to either work in the same physical location or have access to technical infrastructure thatfacilitates creation of shared virtual spaces can optimize patient care by enhancing care coordination, communication and access toservices.28 Co-location of multiple care team members would also help patients reduce the number of visits needed to manage theirT2DM HF, thereby minimizing patient burden and facilitating compliance with care planning. Although patients and clinicians who live inrural areas are less likely to encounter co-location of health care services, roundtable panelists indicated that the growing use of telehealthtechnologies encourages clinicians to rethink shared spaces as they relate to care coordination.Integration of Pharmacists Into the Care TeamIn an ideal T2DM HF care setting, pharmacists are fully engaged members of the care team who assist with medication monitoring,medication reconciliation, patient education and minimizing risk of drug-drug interactions. Pharmacists are available to PCCs andspecialists and, like other members of the care team, have access to all patient information. They play a key role in patient counselingand education on medication management, side effects and the interplay between medication regimens and diet and lifestyle habits.Pharmacists also help address issues related to how SDOH may impact patients’ medication adherence or safety.In an ideal care setting for patients with T2DM HF, pharmacists are available for brief consultations, collaborate with the care team inlong-term care planning and contribute to clinician education about new drugs and the suitability of new products for individual patients.A large body of research supports this vision. A recent Cochrane review highlighted the potential for pharmacists to have a favorableimpact on diverse HF outcomes, including both all-cause and HF hospital readmissions.29 Similarly, a review of 43 pharmacist interventionsfor T2DM showed that these interventions were not only effective in reducing hemoglobin A1c, but that some also had a favorable impacton systolic blood pressure and triglycerides.30Optimal Patient EducationPatients with T2DM HF often have demanding therapeutic regimens that involve multiple medications, lifestyle modifications and frequentoffice visits with PCCs and specialists where medications are initiated, titrated, replaced or supplemented with new products. Patients hearterms they might not understand. They might have to take a variety of medications several times a day, regularly monitor glucose and bloodpressure and follow special diets or weight loss and exercise regimens.Return to Table 1www.ncqa.org11

Optimizing Care for Patients With Type 2 Diabetes and Heart FailureRoundtable panelists emphasized that to be fully compliant with these regimens, patients with T2DM HF require a high degree ofhealth literacy to understand and successfully implement them. They need high-quality, standardized education programs delivered byprofessionals with the training to address their needs. Panelists’ emphasis on patient education echoes existing calls from the AHA and theADA to improve the health literacy and skills mastery needed for optimal self-care.31,32,33Maximized Use of Nonphysician Health Care ProfessionalsIn an ideal care delivery setting, nurse practitioners (NP), physician assistants (PA), health educators and medical assistants (MA) engage inhigher levels of patient care, help coordinate care and deliver patient education for people with T2DM HF. There is ample evidence thatthese professionals can play key roles in management of T2DM HF,34,35 and roundtable panelists were enthusiastic about the promise ofchanneling their knowledge and skills directly into patient care. For example, in addition to providing direct care, NPs and PAs working in bothprimary care and specialty settings could support implementation and monitoring of care plans in collaboration with their patients.Ability to Leverage Information From Community-Based ServicesIn addition to physicians, nurses and “traditional” members of a patient’s health care team, patients often interact with other healthprofessionals regularly, and information from these professionals could provide unique insights into aspects of patient care that are difficultto gauge from office-based encounters.In an ideal care delivery setting, a patient’s traditional health care team has access to and leverages information from community-basedmembers of the team, including community health workers, home care aides and home health nurses who support the patient in theirhome. The ability of community health workers to help manage chronic diseases, enhance patient-provider communication and monitoradherence to treatment plans is well established,36 and roundtable panelists viewed the knowledge and perspective of these and othercommunity-based professionals as an untapped resource that could be leveraged to enhance care for patients with T2DM HF.Supplemental information from these professionals could include observations on the patient’s diet, mental health, social well-being andmedication adherence, as well as their ability to adhere to the care plan. Sharing this information electronically and making it accessibleby all members of the care team would provide a more complete perspective on the patient’s progress, thereby facilitating adjustments tothe care plan that reflect real-world circumstances.Availability of Financial and Other Patient Navigation SupportsPatients with T2DM HF frequently need to arrange many office visits to PCCs and specialists and make multiple trips to the pharmacyto fill an array of prescriptions. Roundtable panelists pointed out that each encounter is associated with a co-payment or co-insuranceobligation and that sicker patients tend to have more out-of-pocket costs because they see more doctors and fill more prescriptions. Patientnavigator programs have been shown to improve processes of care among people with chronic disease, and financial navigation isbecoming more common for health conditions for which high out-of-pocket medication costs often hinder adherence to treatment.37,38Roundtable panelists envisioned a patient care pathway in which economically vulnerable patients have access to financial navigatorswho help them identify cost saving programs and other financial supports that reduce out-of-pocket costs of medication and office visits.Navigators could also help patients manage visit schedules and help them connect with community-based services to supplement theircare plans. One panelist described an externally funded successful navigator program that helped patients transition from hospital to hometo promote favorable post-discharge outcomes.Return to Table 112www.ncqa.org

Barriers to Ideal Care Delivery for PatientsWith Diabetes and Heart FailureRoundtable panelists identified numerous barriers that hinder delivery of ideal care for patients with T2DM HF. Some are linked toresource constraints imposed by the geographic setting in which patients receive care; others stem from practical issues involving effectivecommunication among clinicians and access to health information. Additional barriers to optimizing care are tied to federal and statepolicies on licensure and scope of practice, as well as to coverage services provided by nonphysician health care professionals undercurrent reimbursement policies.Roundtable participants emphasized that in many cases, the structural or insurance barriers that hamper delivery of optimal care forpatients with T2DM HF are multiplied by patient-level factors such a

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