As communities recognize Diabetes Week, Montgomery Cares continues to make meaningful progress in supporting patients with diabetes, according to the latest network performance data. In FY24, approximately 20% of Montgomery Cares patients had a diabetes diagnosis—nearly double the statewide incidence in Maryland—making diabetes prevention, monitoring, and treatment a critical priority for the program.
One of the network’s strongest areas is HbA1c testing, a key measure used to monitor blood sugar levels over time. After tracking close to the HEDIS Medicaid HMO average for several years, Montgomery Cares surpassed the HEDIS benchmark in FY22 and continued improving, reaching a 90% testing rate in FY24. Regular HbA1c testing helps providers identify whether patients are maintaining healthy blood sugar levels and allows care teams to intervene before complications develop.
Blood sugar control has also improved since the pandemic. The share of patients with controlled blood sugar increased from 51% to 57%, reflecting steady recovery and renewed engagement in care. At the same time, the data point to continued need: 31% of Montgomery Cares patients with diabetes have uncontrolled blood sugar, compared with the HEDIS Medicaid HMO average of 35.8%. While the network is outperforming that benchmark—a lower score is better, in this case--roughly one in three diabetic patients remains at increased risk for serious complications, including kidney disease, vision loss, nerve damage, amputations, heart attack, and stroke.
The report highlights several strategies that could help build on this progress. Expanding food-as-medicine programs would provide patients with greater access to healthy foods that support blood sugar control. Integrating nutrition support into chronic condition case management—alongside nursing support—could also help patients stay engaged in care and better manage diabetes and related conditions such as hypertension.
Specialty care access remains another important opportunity. Diabetic retinal exam rates rose from 19% in FY23 to 29% in FY24, but this measure remains well below the HEDIS mean of 53%. Limited access to ophthalmologists, optometrists, and screening equipment continues to be a barrier. PCC’s Project Access team is exploring potential partnerships to help expand retinal screening capacity for Montgomery Cares patients.
Foot exams are also improving after a pandemic-era decline, rising from 32% in FY21 to 43% in FY24. Expanding access to podiatry services and dedicating specialty care funds for annual foot exams could help prevent ulcers, infections, amputations, and other costly complications.
Overall, the latest results show a network that is performing well on diabetes monitoring while continuing to identify practical ways to improve outcomes. With continued investment in specialty care, nutrition support, and chronic condition case management, Montgomery Cares can further strengthen diabetes care, helping more patients avoid preventable complications and lead healthier lives.
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.
One of the network’s strongest areas is HbA1c testing, a key measure used to monitor blood sugar levels over time. After tracking close to the HEDIS Medicaid HMO average for several years, Montgomery Cares surpassed the HEDIS benchmark in FY22 and continued improving, reaching a 90% testing rate in FY24. Regular HbA1c testing helps providers identify whether patients are maintaining healthy blood sugar levels and allows care teams to intervene before complications develop.
Blood sugar control has also improved since the pandemic. The share of patients with controlled blood sugar increased from 51% to 57%, reflecting steady recovery and renewed engagement in care. At the same time, the data point to continued need: 31% of Montgomery Cares patients with diabetes have uncontrolled blood sugar, compared with the HEDIS Medicaid HMO average of 35.8%. While the network is outperforming that benchmark—a lower score is better, in this case--roughly one in three diabetic patients remains at increased risk for serious complications, including kidney disease, vision loss, nerve damage, amputations, heart attack, and stroke.
The report highlights several strategies that could help build on this progress. Expanding food-as-medicine programs would provide patients with greater access to healthy foods that support blood sugar control. Integrating nutrition support into chronic condition case management—alongside nursing support—could also help patients stay engaged in care and better manage diabetes and related conditions such as hypertension.
Specialty care access remains another important opportunity. Diabetic retinal exam rates rose from 19% in FY23 to 29% in FY24, but this measure remains well below the HEDIS mean of 53%. Limited access to ophthalmologists, optometrists, and screening equipment continues to be a barrier. PCC’s Project Access team is exploring potential partnerships to help expand retinal screening capacity for Montgomery Cares patients.
Foot exams are also improving after a pandemic-era decline, rising from 32% in FY21 to 43% in FY24. Expanding access to podiatry services and dedicating specialty care funds for annual foot exams could help prevent ulcers, infections, amputations, and other costly complications.
Overall, the latest results show a network that is performing well on diabetes monitoring while continuing to identify practical ways to improve outcomes. With continued investment in specialty care, nutrition support, and chronic condition case management, Montgomery Cares can further strengthen diabetes care, helping more patients avoid preventable complications and lead healthier lives.
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.
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