Closing Diabetes Care Gaps And Achieving 5-Star Compliance For Diabetic Retinopathy

Mobile medical group’s successful teletretinal program with the WELCH ALLYN RETINAVUE care delivery model.

This national, in-home primary care organization* is a value-based mobile medical group that brings care into the homes of seniors with chronic illnesses. Physician-led interdisciplinary teams coordinate care with patients’ existing primary care physicians and specialists, providing additional support for the most complex patients on their panels.

The RetinaVue care delivery model has been an important component of the organization’s diabetes management program since 2017. Providing increased access to the critical annual diabetic retinopathy screening aligns with the company’s mission, vision and values. More than 8,000 patients nationwide have been screened to date.


With the RETINAVUE care delivery model, we’re breaking down barriers and providing quality care for patients directly in an environment that they’re comfortable with.


-HEDIS Quality Specialist, Mobile Medical Group

Patients often face many barriers when accessing the care they need to manage chronic health conditions. An interdisciplinary team focuses on making sure patients can receive the care they need, either in the community or in their home.

Using the handheld Welch Allyn RetinaVue 700 Imager for in-home screenings, providers can ensure patients receive the care they require. Additionally, the in-home primary care organization accomplishes its goal of helping its health plan partners close care gaps for diabetic retinopathy.

“As a social worker, I’m always about patient advocacy and meeting patients where they’re at,” says a HEDIS quality specialist. “I think the RetinaVue care delivery model combines both of my passions as a social worker and as a HEDIS quality specialist. We’re breaking down those barriers and providing quality care for patients directly in an environment that they’re comfortable with.”



This mobile medical group has successfully achieved CMS 4- and 5-Star ratings for its Healthcare Effectiveness Data and Information Set (HEDIS) Diabetic Retinal Exam (DRE) measure for all its health plans and contracts. “Not only are we able to screen the most vulnerable patients in the comfort of their homes, but we’ve been able to identify various eye pathologies and then help those patients get access to specialty care,” commented a HEDIS quality specialist.


Ambassadors work with patients to schedule and then perform the screenings in their homes. Patients are grateful to be able to complete their screening in an environment and with caregivers they are familiar with. The ambassadors also have a sense of pride for the teleretinal program. The team takes ownership of the program’s goals and metrics and makes it a personal mission to ensure that all patients under their care complete their annual screening. “It gives them a sense of purpose and fulfillment to be able to connect with patients and also contributes to the overall goal of meeting the quality metrics,” said a HEDIS quality specialist.


The program’s success is attributed to the team’s consistent focus on building the program. “My advice is to be patient — it takes time to build out a program,” says a HEDIS quality specialist. “There is a learning curve, but over time staff get more familiar with the imager and the workflow. The Baxter Customer Success team is also very supportive. They provide excellent training, so do as many trainings as you can with them.”

A coordinated training program, ongoing support for practices on workflow and regular reporting to senior leadership contribute to patient and clinician satisfaction, and the ability to continue meeting HEDIS measures. As the organization has expanded into new markets, the RetinaVue care delivery model is implemented at those new sites. “It’s rewarding to be able to provide something tangible to patients that can actually help them get screened and prevent eye disease,” said a HEDIS quality specialist.


*A national, in-home primary care/mobile medical group. Baxter shares success stories while protecting the confidentiality of our clients as needed in a competitive business environment.

Baxter, Hillrom, RetinaVue and Welch Allyn are trademarks of Baxter International Inc. or its subsidiaries.

HEDIS is a trademark of the National Committee for Quality Assurance (NCQA). US-FLC147-230070 V1 07/23