THE MICHIGAN COLLABORATIVE FOR TYPE 2 DIABETES
Shifting the paradigm of type 2 diabetes care through dissemination of best practices and partnering to remove barriers to care.
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2024 Endocrinology Care Coordination QI Projects
In Spring 2024, MCT2D asked our 26 participating Michigan endocrinology practices to work with their physician organization to choose a participating MCT2D primary care practice to partner with to address a care coordination issue between the two practices.
Each partnership group chose its own issue to work on, since MCT2D wanted to allow practices to focus on the specific factors that were impacting their shared patients. This resulted in a large range of projects, including creating more diabetes friendly meal options for hospitalized patients, implementing a consult-lite approach for patients beginning a continuous glucose monitors (CGM), and developing specific plans to refer patients back to primary care after reaching treatment goals with endocrinology.
Why Care Coordination?
One of MCT2D’s primary goals is to enhance collaboration and communication between primary care and specialty practices in the treatment of patients with type 2 diabetes. While both endocrinologists and primary care physicians have been involved in MCT2D since its launch, their primary interaction in MCT2D prior to this project was limited to endocrinologists providing education on CGM and diabetes medications.
This initiative marked the first time both specialties worked together on a meaningful, self-directed care coordination project—one that directly fostered collaboration and delivered mutual benefits.
MCT2D’s 395 participating practices including primary care (blue), nephrology (teal), and endocrinology (orange) across the state.
QI Project Timeline
01 April 2024
All endocrinology practices were required to identify their partnering primary care practice, ahead of our regional meetings so that the clinical champions could meet in person. Clinical champions were encouraged to meet with their partnering PCP practice and PO administrative leads to brainstorm potential areas for collaboration and determine the roles of the PCP practice and endocrinology practice for the proposed partnership.
15 June 2024
Project plans due. Partnering endocrinology and primary care practices submitted their plan to MCT2D including the focus of their work, the role of the PCP practice, the role of the endocrinology practice, their goals, and anticipated challenges. The project was intended to start following the submission of the project plan and continue throughout the value-based reimbursement year, ending in March 2025.
21 November 2024
At the Endocrinology Clinical Champion meeting, three endocrinologists gave a presentation of the work that they were doing and the progress that they had made.
April - May 2025
Spring 2025 MCT2D regional meetings
Each endocrinology practice has created a poster (see sliding gallery below) to showcase the results of their work at each of the seven regional meetings across the state, allowing attendees to learn about these collaborations, including successes and lessons learned.
Highlights from the QI Projects
Collaboration between specialists is important for ensuring that type 2 diabetes patients receive the best care possible. There are numerous opportunities to improve patient care through collaboration, as demonstrated by the vast array of projects chosen by our participating practices.
This is especially important considering that across the state, the wait time to see an endocrinologist can be high, and many of these projects have supported the streamlining of care so that it is provided efficiently and effectively. Projects included revamping the meal options offered to hospitalized T2D patients, offering a consult-lite approach to patients who are just beginning on a CGM, and defining appropriate referrals.
Browse the 2024 Endocrinology and Primary Care Care Coordination QI Projects
Endocrinology Care Coordination QI: Additional Access - E-Consults to improve access to Endocrinology
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Elizabeth Marshall and Dr. Zeina Habib of CMU Health Department of Endocrinology.
Endocrinology Care Coordination QI: Avoiding Lab Duplication
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Smita Bijlani MD, of Smita Bijani, MD PC.
Endocrinology Care Coordination QI: Care Coordination – Working Together – Achieving More
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. David Bradlee – Bloomfield Endocrinology; Dr. Imad Mansoor – CoreMed Plus; Peggy Best, RNCM, MSA.
Endocrinology Care Coordination QI: Early Referral to Endocrinology
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Jamal Hammoud, MD, of Endocrine Consultants of Mid Michigan and Dr. Farhan Khan, MD, of Farhan Khan MD PC.
Endocrinology Care Coordination QI: Endocrinology Access - Decreasing Wait Times
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Amena Iqbal, MD; Dr. Sharon Deskins, MD; Michael Rivette of Corewell Health Royalton Diabetes & Endocrinology and Corewell Health Primary Care Royalton.
Endocrinology Care Coordination QI: Expanding Continuous Glucose Monitoring (CGM) Use in Primary Care
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Abdul Al-Kassab MD on behalf of Endocrine and Diabetes Consultants; Ronald Bellasario MD, on behalf of Stonebrooke Family Physicians.
Endocrinology Care Coordination QI: HbA1c Monitoring
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Wassim Noureddine, MD of Henry Ford Allegiance Endocrinology.
Endocrinology Care Coordination QI: Identifying Medication Non-Adherence
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Ashish Verma, MD, of Endocrine & Metabolic Disorders Center PC.
Endocrinology Care Coordination QI: Improving Provider Communication Between EHR Platforms
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Emilie Collins, MD; Heather Rork, PharmD; and Sue Ek of West Michigan Endocrine PLC and A Plus Family Medicine.
Endocrinology Care Coordination QI: PCP and Endocrinology Referral Process
2024 Endocrinology & Primary Care Care Coordination QI Project, led by Dr. Opada Alzohaili, M.D., F.A.C.E, of Metro Detroit Endocrinology Center.
Next Steps
This project has provided a unique opportunity for primary care providers and endocrinologists to collaborate in ways that were previously uncommon. Each partnership group has specific next steps based on the focus of their collaboration, with most planning to build on the progress and advancements made throughout the year.
The five new endocrinology practices that joined MCT2D this year will be working on PCP partnership projects in 2025, following a similar timeline to the one outlined above.
Additionally, MCT2D will be introducing a performance measure for endocrinologists in 2025, aimed at optimizing billing for continuous glucose monitor (CGM) interpretations. This initiative ensures that patients receive the necessary guidance and support when initiating CGM use.
RESOURCE LIBRARY
Access content for MCT2D members including events, requirements, forms, and more.
VISIT NOWFeatured Resource
Guide for Starting Patients on a Low Carb Lifestyle
A green, yellow, and red light system for adjusting diabetes medications like GLP-1 RAs, DPP-4i's, basal and bolus insulin, and sulfonylureas and monitoring blood glucose and adapting nutrition goals while adopting a low carb lifestyle.
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PROJECTS
Innovative projects addressing type 2 diabetes care in support of MCT2D initiatives.
FEATURED PROJECTS
MCT2D CGM User Experience Program
The CGM UEP program is open to physicians, nurse practitioners, physician assistants, and pharmacists at any MCT2D practice with the goal of building clinicians' familiarity with using a CGM and ultimately, increasing understanding of the patient experience through an off-label provider trial.
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OUR PATIENTS
Innovative projects addressing type 2 diabetes care in support of MCT2D initiatives.
VISIT NOWPatient Perspectives
Meet Frankie, MCT2D patient advisor
Meet Frankie, MCT2D patient advisor Frankie, who started on a lower carb lifestyle with the support of his doctor in September 2021. He's since lost 120 pounds and no longer takes insulin.
“If I could’ve had this information as a young man, my whole life would’ve been different.”
OUR MEMBERS
357
primary care practices24
endocrinology practices14
nephrology practices29/40
of all physician organizations in Michigan
