Improving Insulin Pump Referral in Medicaid-Insured Youth with Type 1 Diabetes: The Experience of a Pediatric Hospital in Southern California

by Jennifer Baldwin

Coauthors: Rebecca Ortiz La Banca Barber PhD RN, Jennifer Baldwin RN CDCES, Deborah Miller RN CDCES, Lily Chao MD

Medical Devices & Digital Health

3 takeaways
1. There is a need for streamlined processes in diabetes clinics to aid Medicaid insured youth with T1D and families in navigating insulin pump referrals. A 9-step referral roadmap including diabetes care and education specialists (DCES), advanced practice providers, endocrinologists, and a researcher showed potential to reduce time between referral to pump treatment and pump initiation in Southern California.
2. Although the team-based approach included evidence-based tools such as roadmaps, competencies assessment and virtual classes, pilot results demonstrated the importance of patient-centered workflows.
3. Having a dedicated team to navigate insulin pump referrals is paramount. Process metrics should be analyzed in team-based approaches before patient-centered outcomes analyses take place. Our pilot results shown opportunities for improved communication between staff and patients and need for individual protected time of diabetes care and education specialists leading pump referral processes.
Continuous insulin infusion systems (CIIS) represent an important advance in type 1 diabetes (T1D) treatment, recommended by national and international guidelines. Despite insurance coverage, CIIS uptake remains suboptimal in youth with T1D. Barriers include the lack of a streamlined process to facilitate technology access, especially for publically-insured patients. At a pediatric hospital in Southern California caring for over 980 Medicaid insured youth with T1D, only 21% wear CIIS.
Research Questions and Specific Aims
By redesigning the CIIS referral process, we aimed to reduce the time between referral to CIIS treatment and CIIS initiation. Our secondary aim was to offer patients a structured process including a team-based approach with diabetes care and education specialists (DCES), advanced practice providers, endocrinologists, and a researcher.
We conducted a literature review to identify the best evidence in team-based approaches for CIIS initiation that could inform our design. Five articles described handouts, competencies assessment, class content, and modality incorporated into our pilot program. A comprehensive 9-step roadmap and surveys were developed to guide the new process. Process metrics were evaluated with descriptive statistics to assess pilots’ success.
In 2022, the median time between CIIS prescription and CIIS start was 136 days. In 2023, after 6 months of the new pump referral process, time was reduced. Process mapping occurred throughout monthly team meetings, with an average of 6 referrals/month. Eligible patients were English speaking with insurance coverage for insulin pump treatment. The DCES team developed two electronic surveys for knowledge checks introduced at virtual class 1, named intro to pump, and at the actual pump start. Barriers identified by the team were related to insurance authorization, fine tuning in communication between participants and team, and education technologies such as pre-recorded videos.
Although early pump start is recommended by national guidelines, patient-centered workflows are necessary to meet patient and family needs, especially when working with a diverse patient population. Our team-based approach had some successes and bottlenecks in the first 6 months. Future projects should include a patient/family advocate in our team and workgroups for tackling specific barriers encountered.