A patient living with type 2 diabetes comes in on a busy fall afternoon. They feel fine, the conversation turns to a refill and a sore knee, and the visit ends before anyone notices that this year’s A1c was never drawn, that the spring eye referral never came back with a report, or that the last blood pressure in the chart is the high one from the summer. Each is easy to miss on a full schedule, and each is part of the same person’s diabetes care. It is the idea behind the line along the bottom of our A1c guide: make every diabetes visit count [1].
One patient, four needs
The same patient, in the same year, is counted in several diabetes measures at once. The A1c measure, Glycemic Status Assessment for Patients with Diabetes (GSD), looks at the most recent A1c or glucose management indicator (GMI) result of the year for adults 18 to 75 with type 1 or type 2 diabetes, and it reports two rates: the share of patients under 8.0% and the share over 9.0% [1]. Blood pressure control (BPD) asks whether that same patient’s most recent reading of the year is under 140/90 mm Hg [2], the eye exam measure (EED) looks for a qualifying retinal eye exam during the year [3], and the kidney health evaluation (KED) asks for both an eGFR and a urine albumin-creatinine ratio [4].
What these measures share is a quiet expectation that something was actually done and written down. A test that never happens cannot show control, and our A1c guide says plainly that missing testing or results may negatively affect performance [1]. So the patients worth finding first are often the ones with no A1c at all this year, and one visit planned around all four needs does more than four separate reminders.
Five steps from our quality guides
Our Quality team published quality guides for GSD, BPD, and EED in August 2026, and each one is built on the same five steps: identify, order or refer, document the actual result, act, and recheck [1] [2] [3]. Your Practice Performance Advisor can share copies of all three, and the kidney health evaluation guide is linked from our Year-End Quality Playbook [5].
Identify
The work starts before the visit. CareEmpower®, our care coordination platform, helps a practice see which patients with diabetes have no result yet this year, whose most recent A1c or blood pressure is above goal, and who has no completed retinal eye exam on record [1] [2] [3]. Folding that into pre-visit planning puts every open need in view before the patient walks in.
Order or refer
The A1c guide suggests ordering the test before or at the visit, and using standing lab orders when appropriate [1]. Qualifying GMI data from a continuous glucose monitor can also count [1]. Kidney health needs an eGFR and a uACR together [4], which makes it a natural companion to the A1c draw. For the eyes, a provider can refer to an optometrist or ophthalmologist, use eligible remote retinal imaging, or complete an autonomous AI eye exam in the office [3].
Document the actual result
This is where care that really happened can still go uncounted. A note that says “controlled” or “at goal” does not show the number, so our guides ask for the date and the actual value: the numeric A1c or GMI, both the systolic and the diastolic reading, and, for the eyes, the exam date and whether retinopathy was present or absent [1] [2] [3]. Each guide lists the CPT II result codes that turn those values into reportable evidence. With eye exams, a referral alone does not show completion, which is why the guide encourages practices to obtain the report and record the result in the chart [3].
Act
When a patient is not at goal, the guides point toward the conversations providers already know well: medications, adherence, nutrition, education, and the barriers that make any of those hard, followed by a plan for follow-up [1] [2]. When the barrier is not clinical, a practice can refer the patient to the Equality Health (EH) Care Team from CareEmpower [6].
Recheck
Because the most recent result of the year is the one that counts, an elevated A1c or blood pressure in the summer does not have to be the last word [1] [2]. When follow-up is clinically appropriate, a repeat reading later in the year tells the fuller story, and keeping track of open eye referrals through the fall leaves time to close the loop before December ends [3].
What we are doing alongside you
Each month, EH chooses quality measures to focus on, and in November the focus is the A1c measure, alongside cervical cancer screening [7]. In CareEmpower, the worklist can highlight the month’s focus measures and narrow the list to patients with those needs who are past due or due within the next 90 days [7].
ECIP, our activity-based payment program, also includes Chronic Care Management, a monthly visit opportunity that opens when a condition such as diabetes comes together with a change like a new medication, a hospital stay, or an ER visit [4].
For patients who have drifted away from primary care, our Care Specialists and community health workers reach out by phone, by text, and in person to reconnect them with their own provider. In one Arizona payer partnership, members we re-engaged showed 35% higher A1c control than members we could not reach, and in one Texas payer partnership the difference was 121% [8]. When they come back, the visit you have already planned is ready for them.
A visit that does more
None of this asks a practice to work harder, only for a little planning before the visit and a little care in how results are written down. To the providers, nurses, medical assistants, and front-desk teams who draw the labs, repeat the readings, and chase the eye reports, thank you. We are grateful to work alongside you.
References
[1] Equality Health. “Glycemic Status Assessment for Patients with Diabetes (GSD)” Quality Guide. August 2026, pp. 1–2.
[2] Equality Health. “Blood Pressure Control for Patients with Diabetes (BPD)” Quality Guide. August 2026, pp. 1–3.
[3] Equality Health. “Eye Exam for Patients with Diabetes (EED)” Quality Guide. August 2026, pp. 1–3.
[4] Equality Health. “2026 ECIP Reference Guide” (provider-facing). 2026, slides 6 and 9.
[5] Equality Health. “Here’s Your Year-End Quality Playbook.” September 2, 2026. https://equalityhealth.com/blogs/year-end-quality-playbook/
[6] Equality Health. “Pathways to Better High Risk Member Management (HRM).” June 2025, pp. 1–3.
[7] Equality Health. CareEmpower® Quality Focus worklist feature and 2026 quality focus calendar. October 2026.
[8] Equality Health Arizona and Texas payer partnership performance data.
