# Clinical Cases: Practice Management and Systems

## Case 1: Quality Improvement - Diabetes Care

### Practice Setting
- **Practice:** Community Family Medicine Clinic
- **Patient Panel:** 4,500 patients
- **Providers:** 3 physicians, 2 nurse practitioners
- **Location:** Suburban area, mixed socioeconomic population

### Quality Improvement Challenge

The practice has received its quarterly quality report from their accountable care organization. Their diabetes mellitus HbA1c control measure is underperforming:

**Current Performance:**
- Patients with diabetes who have HbA1c <8%: 62%
- ACO target: 75%
- National benchmark: 70%

This performance gap affects both patient health outcomes and practice reimbursement under their value-based contract.

### QI Team Formation

**Team Members:**
- Lead physician (QI champion)
- Medical assistant
- Registered nurse (care coordinator)
- Front desk staff member
- Practice manager
- Patient representative

### Plan-Do-Study-Act (PDSA) Cycle 1

**PLAN:**

*Problem Identification:*
- Reviewed diabetes registry: 485 patients with diabetes
- 302 (62%) at goal HbA1c <8%
- 183 (38%) not at goal

*Root Cause Analysis:*
1. Many patients overdue for HbA1c (no test in >6 months): 28%
2. Patients with elevated HbA1c not returning for follow-up: 35%
3. Medication intensification not occurring at visits: observed in chart review
4. Patient education and self-management support inconsistent

*Aim Statement:*
"We will increase the percentage of patients with diabetes who have HbA1c <8% from 62% to 70% within 6 months."

*Intervention Selected for First Cycle:*
Address the testing gap - patients overdue for HbA1c monitoring

*Specific Change to Test:*
Pre-visit planning to identify diabetic patients due for HbA1c, with standing order for lab to be completed before the appointment.

**DO:**

*Implementation (Small Scale Test):*
- Tested with one provider's panel for 2 weeks
- MA reviews schedule 1 week in advance
- Identifies patients with diabetes
- Checks if HbA1c done in past 3 months
- If not, sends order to lab with instruction to complete before appointment
- Patient contacted by phone/portal with lab order

*Data Collection:*
- Number of patients identified as needing HbA1c
- Percentage who completed lab before visit
- Provider satisfaction with process
- Time added to MA workflow

**STUDY:**

*Results After 2-Week Pilot:*
- 24 diabetic patients identified on provider schedule
- 14 (58%) were overdue for HbA1c
- 10/14 (71%) completed HbA1c before their visit
- Average additional MA time: 5 minutes per patient identified
- Provider reported: "This is incredibly helpful - I can make real-time treatment decisions"
- Barrier identified: Some patients couldn't afford lab copay before visit

**ACT:**

*Decision:* ADOPT with modifications
- Roll out to all providers
- Add financial counseling for patients with lab cost barriers
- Integrate into daily huddle workflow

### PDSA Cycle 2

**PLAN:**

*Next Problem:* Patients with elevated HbA1c not returning for timely follow-up

*Intervention:* Nurse care manager outreach to patients with HbA1c >9% who have not scheduled follow-up within 2 weeks

**DO:**
- Tested for 4 weeks with all patients with HbA1c >9%
- Care manager calls within 3 days of lab result
- Reviews medication adherence, barriers to care
- Schedules follow-up appointment
- Completes warm handoff to pharmacist if medication issues identified

**STUDY:**
- 18 patients with HbA1c >9% identified
- 16/18 (89%) reached by phone
- 14/16 (88%) scheduled follow-up within 3 weeks
- Common barriers identified: medication cost, transportation, understanding of diabetes

**ACT:**
- Adopt as standard workflow
- Expand to patients with HbA1c 8-9%
- Create resource list for common barriers

### Clinical Image
![PDSA Cycle Diagram](case_01_image.jpg)

*Image: The Plan-Do-Study-Act quality improvement cycle showing the iterative process of planning an intervention, testing on a small scale, analyzing results, and deciding whether to adopt, adapt, or abandon.*

**Image Source:** Wikimedia Commons
**Attribution:** Based on IHI Model, Educational Use
**URL:** https://commons.wikimedia.org/wiki/File:PDSA_cycle.png

### Results After 6 Months

**Process Measures:**
- HbA1c testing rate within 6 months: 72% → 91%
- Follow-up scheduling rate for HbA1c >8%: 45% → 82%
- Pre-visit labs completed: 0% → 68%

**Outcome Measures:**
- HbA1c <8%: 62% → 71% (goal was 70%)
- HbA1c <9%: 78% → 86%

**Balancing Measures:**
- Provider satisfaction improved (pre-visit data availability)
- MA workload increased but manageable with workflow redesign
- No increase in patient complaints

### Teaching Points

1. **PDSA cycles are iterative** - test small, learn, adapt, then spread

2. **Root cause analysis before intervention** - understand WHY before deciding WHAT

3. **Aim statements should be specific and measurable** - "improve diabetes care" is not actionable

4. **Balance measures prevent unintended consequences** - improving one metric shouldn't worsen another

5. **Multidisciplinary team involvement** is essential - front desk and MAs often have the best process insights

6. **Quick wins build momentum** - start with achievable changes that demonstrate value

---

## Case 2: Prior Authorization and Patient Advocacy

### Patient Case

**Patient:** Ms. Carmen Rodriguez
**Age:** 58 years old
**Insurance:** Commercial HMO

### Clinical Scenario

Ms. Rodriguez is a 58-year-old woman with type 2 diabetes mellitus, currently on maximum-dose metformin and glipizide, with HbA1c of 8.9%. She has tried and failed to tolerate pioglitazone due to edema. Based on her cardiovascular risk profile (hypertension, dyslipidemia, obesity) and inadequate glycemic control, you want to prescribe a GLP-1 receptor agonist (semaglutide), which has demonstrated cardiovascular benefit.

### The Prior Authorization Process

**Day 1: Initial Prescription**

You submit an electronic prescription for semaglutide (Ozempic) 0.25 mg weekly, with titration plan. The pharmacy contacts your office: "Prior authorization required. Coverage denied without PA."

**Day 2: Prior Authorization Submission**

Your staff submits the prior authorization request including:
- Diagnosis: Type 2 diabetes mellitus, uncontrolled (ICD-10: E11.65)
- Current medications and duration of use
- HbA1c values showing inadequate control
- Contraindication/intolerance to pioglitazone (documented edema)
- Clinical rationale: cardiovascular risk reduction based on ADA guidelines

**Day 5: Initial Denial**

Denial letter received:
- Reason: "Patient has not tried an SGLT2 inhibitor before GLP-1 agonist"
- Insurance requires step therapy: SGLT2 inhibitor trial before GLP-1 coverage

### Clinical Image
![Prior Authorization Workflow](case_02_image.jpg)

*Image: Flowchart showing the prior authorization process from initial request through documentation, submission, denial, appeal, peer-to-peer review, and external review options.*

**Image Source:** Wikimedia Commons
**Attribution:** Administrative workflow, Educational Use
**URL:** https://commons.wikimedia.org/wiki/File:Prior_authorization_flow.png

### Appeal Process

**Day 6: First-Level Internal Appeal**

You submit an appeal letter:

---

*Dear Medical Director,*

*I am writing to appeal the denial of coverage for semaglutide (Ozempic) for my patient, Carmen Rodriguez.*

*Ms. Rodriguez has type 2 diabetes with HbA1c 8.9% despite maximum-dose metformin (2000 mg daily) and glipizide (20 mg daily) for over 12 months. She has documented intolerance to pioglitazone (peripheral edema requiring discontinuation).*

*While your step therapy protocol suggests SGLT2 inhibitor trial before GLP-1 agonist, I am requesting an exception based on the following clinical factors:*

*1. Ms. Rodriguez has stage 3 chronic kidney disease (eGFR 42 mL/min). SGLT2 inhibitors require dose adjustment and have reduced efficacy at this level of renal function.*

*2. She has a history of recurrent urinary tract infections (3 in the past year). SGLT2 inhibitors increase UTI risk.*

*3. Per ADA Standards of Care, GLP-1 agonists with proven cardiovascular benefit are recommended for patients with established ASCVD or high cardiovascular risk. Ms. Rodriguez has documented coronary artery disease (prior NSTEMI, 2021).*

*I am requesting coverage of semaglutide based on medical necessity and published guidelines supporting GLP-1 agonist use in her clinical situation.*

*Sincerely,*
*[Physician name and credentials]*

---

**Day 10: Appeal Denied**

Second denial received: "Clinical information reviewed. Original decision upheld."

### Peer-to-Peer Review

**Day 11: Request Peer-to-Peer Review**

You request to speak directly with the insurance company's medical director.

**Peer-to-Peer Call:**

*Insurance Medical Director:* "I see the appeal was denied because she hasn't tried an SGLT2 inhibitor."

*You:* "Thank you for taking my call. I understand your step therapy protocol, but I'd like to discuss why this patient has specific contraindications. She has CKD stage 3 with eGFR of 42 - SGLT2 inhibitors have reduced glycemic efficacy at this level of renal function. More importantly, she has a history of recurrent UTIs, which SGLT2 inhibitors would likely worsen. Additionally, with her cardiovascular history - she had an NSTEMI in 2021 - the ADA specifically recommends GLP-1 agonists with proven cardiovascular benefit like semaglutide."

*Insurance Medical Director:* "Can you send me her renal function labs and cardiology records documenting the NSTEMI?"

*You:* "Absolutely. I can have those faxed within the hour."

**Day 12: Approval**

After review of additional documentation, prior authorization approved for 12 months.

### Documentation

**Important elements documented in chart:**
- Prior authorization process and timeline
- Clinical rationale for medication selection
- Appeals submitted and responses received
- Peer-to-peer conversation details
- Final approval with authorization number

### Impact on Patient

**Without Advocacy:**
- Patient would have been denied evidence-based treatment
- Forced to try medication less appropriate for her clinical situation
- Delay in achieving glycemic and cardiovascular goals

**With Advocacy:**
- Received appropriate medication for her clinical profile
- Total delay: 12 days (still problematic, but resolved)
- Clinical goals can now be addressed

### Teaching Points

1. **Prior authorization is often necessary but delays care** - track denials and appeals to identify patterns

2. **Documentation is key** - include diagnoses, current medications, prior trials/failures, and guideline citations

3. **Know when to escalate:**
   - First-level appeal: Written clinical justification
   - Peer-to-peer review: Direct physician-to-physician discussion
   - External review: Independent third-party review (patient's right)

4. **Cite evidence-based guidelines** (ADA, ACC, etc.) - harder to deny when standard of care is clearly documented

5. **Document everything** - protects the patient and practice, identifies systemic issues

6. **Advocacy is part of medical practice** - the patient cannot navigate this system alone

---

## Case 3: Social Determinants of Health

### Patient Case

**Patient:** Mr. Tyrone Williams
**Age:** 54 years old
**Insurance:** Medicaid

### Clinical Scenario

Mr. Williams is a 54-year-old man with poorly controlled type 2 diabetes (HbA1c 11.2%), hypertension, and obesity. He has missed several appointments over the past year. When he does come in, his prescriptions are often not filled. Today, he presents for an urgent visit because he "doesn't feel right."

### Initial Assessment

**Chief Complaint:** "I've been dizzy and my vision has been blurry for a couple weeks."

**Vital Signs:** BP 178/102, HR 88, BMI 34

**Labs Obtained:** HbA1c 11.8%, fasting glucose 287 mg/dL

**Clinical Findings:** Diabetic retinopathy on fundoscopic exam, peripheral neuropathy

### Deeper History - SDOH Screening

During the visit, you use a validated SDOH screening tool (PRAPARE).

**Housing:**
- "I lost my apartment 3 months ago. I've been staying with different friends and family."
- Currently sleeping on cousin's couch
- No permanent address

**Food Security:**
- "Sometimes I run out of food before I have money to buy more." - YES
- "I skip meals so my grandkids can eat." - YES

**Transportation:**
- "I don't have a car. I take the bus but sometimes I can't afford the fare."
- Missed last appointment because bus route changed

**Medications:**
- "I can't afford all my medications. I take the diabetes one but not the blood pressure one."
- Fills prescriptions when he can afford copays
- Has been rationing insulin

**Employment:**
- Lost job 4 months ago due to company downsizing
- Looking for work but "hard when you don't have a permanent address"

### Clinical Image
![Social Determinants of Health](case_03_image.jpg)

*Image: Framework showing the five domains of social determinants of health: economic stability, education, healthcare access, neighborhood/built environment, and social/community context.*

**Image Source:** Wikimedia Commons
**Attribution:** Based on Healthy People 2030 framework, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:SDOH_framework.png

### Assessment

**Medical Diagnoses:**
1. Type 2 diabetes mellitus, uncontrolled with retinopathy and neuropathy
2. Hypertensive urgency
3. Obesity

**Social Diagnoses (ICD-10 Z codes):**
- Z59.0 - Homelessness
- Z59.4 - Lack of adequate food
- Z72.9 - Problem related to lifestyle (transportation barrier)
- Z56.0 - Unemployment

### Understanding the Root Cause

Mr. Williams' diabetes is not poorly controlled because he doesn't care or doesn't understand his disease. It's poorly controlled because:
- He cannot afford his medications consistently
- He cannot eat the regular, healthy meals required for diabetes management
- He cannot attend appointments reliably
- He is under enormous stress from housing instability
- His insulin requires refrigeration, which is difficult without stable housing

### Integrated Medical and Social Intervention

**Medical Management:**
- Addressed hypertensive urgency (clinic observation, oral medications)
- Adjusted diabetes regimen to more affordable options:
  - Switched from brand insulin to NPH + regular (available at $25/vial without insurance at some pharmacies)
  - Continued metformin (affordable generic)
- Ophthalmology referral for retinopathy
- 2-week follow-up scheduled

**Social Work Referral (same-day warm handoff):**

*Housing Resources:*
- Emergency shelter information
- Referral to Housing Authority for Section 8 application
- Connected to local homeless services coordinator

*Food Resources:*
- Local food bank referral
- SNAP (food stamps) application assistance
- Information about free meal programs

*Medication Assistance:*
- Pharmaceutical patient assistance programs
- 340B pharmacy referral (reduced-cost medications)
- State pharmaceutical assistance program enrollment

*Transportation:*
- Medical transportation benefit through Medicaid (arranged rides to appointments)
- Information about subsidized bus passes

*Employment:*
- Referral to workforce development center
- Information about job training programs

### Documentation

In the EHR:
- Z codes documented for social diagnoses
- Social work note attached
- Follow-up plan includes both medical and social components
- Care manager assigned for ongoing support

### Follow-Up (6 weeks later)

**Progress:**
- Staying in transitional housing with case management support
- Receiving SNAP benefits and using food bank
- Medications filled through patient assistance program
- Attended ophthalmology appointment (transportation arranged)
- HbA1c: 10.1% (improved from 11.8%)
- BP: 144/88 (improved)
- Taking all medications as prescribed

**Ongoing Plan:**
- Continue care coordination
- Monthly visits until stabilized
- Working with housing case manager on permanent housing
- Continued food bank and SNAP

### Teaching Points

1. **Screen for SDOH systematically** - validated tools (PRAPARE, AHC HRSN) identify needs efficiently

2. **Social factors often explain "non-compliance"** - before labeling a patient as non-adherent, understand their circumstances

3. **Document social diagnoses with Z codes** - enables tracking, demonstrates medical necessity, supports care coordination

4. **Build community resource connections:**
   - Know your local food banks, housing services, transportation options
   - Develop relationships with community organizations
   - Use platforms like findhelp.org or Unite Us to identify resources

5. **Warm handoffs are more effective than cold referrals** - introduce the patient to the social worker or care coordinator in person

6. **Social interventions are medical interventions** - addressing food insecurity in a diabetic patient is as important as prescribing metformin

7. **Health equity requires addressing root causes** - disparities in health outcomes are often rooted in social determinants

---

## Key Teaching Points Summary

### Quality Improvement
- PDSA cycles: Plan (identify problem, design intervention), Do (test on small scale), Study (analyze results), Act (adopt, adapt, or abandon)
- Root cause analysis before intervention
- Specific, measurable aim statements
- Multidisciplinary team involvement
- Track process, outcome, and balancing measures

### Prior Authorization and Advocacy
- Documentation is essential: diagnoses, current medications, prior trials, guideline citations
- Know the escalation pathway: written appeal → peer-to-peer → external review
- Cite evidence-based guidelines
- Document everything for patient and practice protection
- Advocacy is a core physician responsibility

### Social Determinants of Health
- Screen systematically with validated tools
- Social factors often explain "non-compliance"
- Document with ICD-10 Z codes
- Build community resource connections
- Warm handoffs are more effective than cold referrals
- Addressing SDOH is a medical intervention