Unsure where to begin?

Here’s a step-by-step guide to getting started with personal and professional CGM devices in your practice.

According to the 2021 American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons with Diabetes Mellitus, the following individuals would benefit from routine use of continuous glucose monitoring:

  • All persons with diabetes treated with intensive insulin therapy, defined as ≥ 3 injections of insulin per day or the use of an insulin pump [Recommendation 2.1.1, Grade A]
  • All individuals with problematic hypoglycemia (frequent/severe hypoglycemia, nocturnal hypoglycemia, and hypoglycemia unawareness) [Recommendation 2.1.3, Grade A]
  • Pregnant women with T1D and T2D treated with intensive insulin therapy [Recommendation 2.1.5, Grade A]
  • CGM may be recommended for individuals with T2D who are treated with less intensive insulin therapy [Recommendation 2.1.8, Grade B]

Grunberger G, et al. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons with Diabetes Mellitus. Endocrine Practice. 2021;27:505-537. https://pubmed.ncbi.nlm.nih.gov/34116789/

CGM devices are either owned by the user for personal use or owned by the health care center for professional use. Clinic-based and owned CGM devices (Professional CGM) are placed on the patient in the provider’s office and used on a short-term basis (~3–14 days). Glucose data may be blinded or visible to the person wearing the device. At the end of the recording period, the device is returned to the clinic, glucose data are downloaded, and the information is reviewed with the patient, providing insights to help inform diabetes management.

Personal CGM devices are owned by the person with diabetes and can be used either continuously or intermittently. Patients use the information in real time to make decisions about their diabetes management. Using data collected from the personal CGM, patients together with their diabetes care team can retrospectively review the Ambulatory Glucose Proflie (AGP) Report, identify any problematic glycemic patterns, discuss potential contributing factors and potential solutions, and an develop action plan to improve diabetes management.

Step-by-Step Instructions for Integrating Professional CGM in Clinical Practice
Step-by-Step Instructions for Integrating Personal CGM in Clinical Practice

Steps to Develop a PROFESSIONAL CGM Program


Establish genuine need for your professional CGM program.

  • Outline benefits to the people with diabetes, providers, and practice
    • What does your practice hope to gain?
    • Will it solve current problems?
    • Will it improve the diabetes metrics in your practice?
  • Are you currently doing all that you can to reduce your patients’ HbA1C levels and optimize their diabetes management?

Step 1 Checklist:

  • Meet with administration and business leaders to discuss the challenges and value of a professional CGM program
  • Meet with other providers or diabetes educators to identify current challenges with managing people with diabetes and opportunities to improve
  • Meet with support staff to identify any concerns they have and obtain their buy-in
  • Identify outcomes of a successful Professional CGM program, both to people with diabetes and to the practice

TIP:  Reach out to colleagues at other practices with an already established Professional CGM program and network with them about what worked, and what didn’t go as hoped when getting the program started. Continue to utilize such contacts as a resource as you implement your program.

Enthusiastic and well-qualified team members will ensure a successful launch of the program.

  • Identify who will be on the team and what their roles will be
  • A diabetes educator/certified diabetes educator (CDE) can be extremely valuable to the team, if you have one on your staff

Step 2 Checklist:

  • Identify the members of your team
  • Define roles and responsibilities of each team member
  • Meet as a team regularly
  • Seek ongoing feedback from all involved parties

TIP:  Anticipate barriers and be prepared to address them. Seek ongoing ideas from all and don’t be averse to changing direction if warranted. Actively seek to minimize disruption to current workflow.

Defining the billing process before you begin will help to ensure that all potential roadblocks are anticipated, identified, and addressed.

  • Make a list of common insurance payors that your patients may have
  • Investigate what their polices are surrounding Professional CGM use
  • Educate staff on the billing codes to utilize for Professional CGM

Step 3 Checklist:

  • Identify the team member to be accountable for the coordination of insurance benefits and requirements
  • Provide an in-service for staff on coding, billing, and documentation requirements for Professional CGM
  • Identify team member(s) to perform ongoing coding and billing audits of individuals in the program

TIP:  Mapping out the billing process before you begin will help prevent the delivery of non-covered services.

Evaluate the currently available devices to determine the best option(s) for your practice. Consider the following:

  • Care between use (is any cleaning/disinfecting required or are components disposable?)
  • Logging of other events (can exercise, food intake, medication, etc be logged electronically?)
  • Length of wear (sensor life varies with different products)
  • Blinded or unblinded (determine if you would like glucose data to be visible or blinded for the person using the device)
  • Data/reports (compare the downloadable reports with each device for ease of interpretation and completeness

Step 4 Checklist:

  • Meet with the manufacturer representatives for the devices that you are interested in
  • Schedule vendor presentations of devices with members of your team
  • Evaluate each vendor for information technology support, customer service, and business processes
  • Choose a vendor that will support you during the implementation period and beyond

TIP:  Consider testing all available devices to fully understand the processes for each of them.

Once you have determined which device you will purchase and stock in your program, you will need to make a contract with the vendor.

  • You will need to address customer service, IT support, and other business needs.

Step 5 Checklist:

  • Determine where you will store your device components
  • Identify the team member responsible for inventory management and ensuring that devices are charged/ready for use
  • Does software need to be installed for downloading data from the device? Which computer(s) will be used? Do you need approval from your internal IT support?
  • Place vendor contact information in a prominent location for all staff to access as needed
  • Estimate the budget required to obtain and maintain device components
  • Outline clear and measurable goals for vendor contract

TIP:  Good vendor relations are an important piece of the success of your Professional CGM Program. Meet with your local representative at regularly scheduled intervals. Optimal inventory management will be a vital factor when calculating return on investment for your program.

Staff will need to be trained on patient selection, use/maintenance of the device, providing instructions to patient, diagnosis/coding/billing, documentation, interpretation, and the process for dissemination of results to patient.

Step 6 Checklist:

  • Develop a protocol that lists characteristics that would make individuals most likely to benefit from Professional CGM
  • Set up vendor training sessions for all involved staff
  • Develop staff competencies, so their sklils will be documented
  • Set up provider training for diagnosis/coding/billing, interpretation, and documentation of download
  • Start planning annual training refresher now

TIP:  Providing thorough pre-implementation training will help to ensure a smooth start to the program. Solicit staff feedback frequently. Consider recording the training sessions so that new staff in the future will have access to it.

Adding a Professional CGM Program to your practice will require changes to your current workflow.

Step 7 Checklist:

  • Seek input from all team members regarding the design of the workflow
  • Document the patient visit from beginning to end
  • Update existing protocols or document new ones to accommodate this new workflow in daily practice
  • Plan for enhanced staffing levels as you roll out the new program
  • Provide support and resources surrounding the new workflow
  • Solicit staff feedback at every step of the way
  • Plan for ongoing scheduled evaluation of the workflow
  • Determine what data you want to collect ongoing

TIP:  It is important to consider all perspectives when designing the workflow, including that of the person with diabetes, the support staff, and the providers. Consider including a patient representative to assist with design, implementation, and evaluation of the workflow to ensure that you fully understand their perspective.

Ensure that all team members are aware of their roles and responsibilities.

  • Proper staff preparation will make sure that the team is on board with the plan and motivated to put in their best effort to help make it a success.

Step 8 Checklist:

  • Host a program launch kick-off event and review roles/responsibilities
  • Identify staff “superusers” who can serve as resources to others
  • Have vendor and IT available during implementation
  • Make device procedure reference materials and troubleshooting guides widely available
  • Provide a forum for staff to provide feedback and suggestions

TIP:  Keep an open communication line with team members and involved staff. It is important that the team feels that this is a collective effort and that everyone’s feedback is equally important.

The Professional CGM Program will require frequent and active input from the person with diabetes.

  • It is vitally important to hold a conversation with the individual with diabetes that provides education for them about the importance of tracking food intake, exercise, and diabetes medication timing. They need to know that this information is necessary for optimal interpretation of CGM results.

Step 9 Checklist:

  • Develop a handout that discusses the benefits of Professional CGM and the importance of keeping a log of food intake, activity, and diabetes medication
  • Check insurance benefits for Professional CGM. Complete prior authorization with insurance company if needed. Write a letter of medical necessity if needed.
  • Have a person sign a consent form for insertion of the CGM sensor if needed
  • Schedule return appointment for patient to return the sensor and review interpretation with the provider. Many patients will mali back their sensor; some providers will provide their interpretations via telephone.

TIP:  Make the person with diabetes the centerpiece of the program. Remember that the most prepared person will yield the best interpretation of the data. Spend time up front on education and support to ensure their understanding of the process and goals of the program.

You are now ready to try out your new program!

  • Stress the importance of educating and preparing the patient with the team
  • Solicit feedback and ideas from staff and patients throughout the implementation process
  • Start tracking success measures at program initiation

Step 10 Checklist:

  • Provide on-site technical and product support resources to staff during launch
  • Perform frequent check-ins with staff at this beginning phase of the program implementation
  • Schedule a weekly staff meeting to discuss how things are going
  • Start collecting any data that you will want to analyze ongoing now
  • Walk through the process from start to finish

TIP:  If possible, try to have some cushion in your staffing during this time. This will enable staff to take the time necessary to fully learn and practice the new procedures and processes. Communicate frequently with support staff to identify any challenges or obstacles to program success. Utilize vendor support and IT support to ensure a smooth implementation.

Program evaluation is an ongoing process.

  • Refer often to the metrics of program success that you have identified
  • Practice continuous quality improvement
  • Be thoughtfully and quickly responsive to suggestions/ideas/feedback

Step 11 Checklist:

  • Compile and sort staff feedback
  • Analyze and evaluate the data that you have collected
  • Compare diabetes outcome post-Professional CGM Program to pre-program outcomes
  • If you are not meeting success metrics, reevaluate your program process and amend as necessary
  • If you are meeting success metrics, disseminate the results widely
  • Meet with the entire team to determine next steps. Is the program the right size? Does it have the right composition of staff? Is device inventory satisfactory?

TIP:  Establish a timeline for ongoing program evaluation. A program may not attain the expected measures of success in the first few rounds of evaluation. Staff will become more efficient with the program processes as time goes by. Ease of use will improve, and staff confidence and competence will show ongoing improvements as well.

Planning for the future of your Professional CGM program is a crucial component of a successful program.

  • What are the next steps for your program?
  • Do you want to establish a satellite location?
  • Do you want to start incorporating Personal CGM into your practice?
  • Do you want to start working with patients remotely?
  • Do you want to offer an additional CGM product in your program?

Step 12 Checklist:

  • Hold a meeting with the entire team to discuss future goals for the program
  • Explore feasibility of the goals

TIP:  Remember to include administration when planning for the future of the program.

Steps to Develop a PERSONAL CGM Program


Identify the feasibility of the program through evaluation of your population and of support structures within your practice setting.

  • Are you currently doing all that you can to reduce your patients’ HbA1C levels and optimize their diabetes management?
  • How could personal CGM benefit your patient population?
  • Would your patient population be amenable to personal CGM?
  • Are the providers in your practice resourced appropriately to support a personal CGM program?
  • What does your practice hope to gain by implementing this program?
  • How could a personal CGM program add value to your patients, providers, and practice?
  • Could it help to improve the diabetes care provided in your practice?
  • Could it help improve the diabetes metrics in your practice?

Step 1 Checklist:

  • Categorize your diabetes population by types of diabetes therapies they utilize
    • What percent uses multiple daily insulin injections or insulin pumps?
    • What percent uses basal insulin plus orals or other injectables?
    • What percent uses oral agents that may cause hypoglycemia, such as sulfonylureas, etc?
    • How many are currently utilizing personal CGM devices?
  • Meet with the members of your healthcare team to identify pros and cons of using personal CGM to manage people with diabetes in your practice
  • Meet with all important stakeholders (leadership team, support staff, etc) to identify any concerns they have and obtain their buy-in
  • Identify outcomes of a successful Personal CGM Program, to people with diabetes, the providers, and to the practice

TIP:  Reach out to colleagues at other practices with an already established Personal CGM Program and network with them about what worked, and what didn’t go as hoped when getting the program started. Continue to utilize such contacts as a resource as you implement your program. Professional CGM implementation can be an important steppingstone for preparation of personal CGM implementation.

Enthusiastic and well-qualified team members will ensure a successful launch of the program.

  • Identify who will be on the team and what their roles will be
  • A diabetes educator/certified diabetes educator (CDE) can be extremely valuable to the team, if you have one on your staff
  • A pharmacist can provide medication-related expertise, which can add value to a personal CGM program because they can work with the patient and physician to make adjustments to the treatment plan based on CGM results
  • A person that is knowledgeable downloading CGM devices will be vital to the team
  • The CGM device company representative may be part of your team to assist with device training and follow-up

Step 2 Checklist:

  • Identify the members of your team
  • Define roles and responsibilities of each team member
  • Meet as a team regularly
  • Seek ongoing feedback from all involved parties

TIP:  Seek ongoing ideas from all and don’t be averse to changing direction if warranted.

Adding a Personal CGM Program to your practice will require changes to your current workflow.

  • It is helpful to define the Personal CGM process from start to finish so that you have a clear understanding of all steps.

Step 3 Checklist:

  • Seek input from all team members regarding the design of the workflow
  • Define the workflow of an in-person visit from beginning to end:
    • Include specifics about patient selection, use of the device, providing education to patient, diagnosis/coding/billing, documentation, downloading and interpreting results
  • Define the workflow of a remote monitoring visit from beginning to end
  • Update existing protocols or create new ones to accommodate this new workflow in daily practice
  • Plan for enhanced staffing levels as your roll out the new program
  • Identify necessary resources that will support the new workflow (e.g., a designated computer and/or printer)
  • Solicit staff feedback every step of the way
  • Plan for ongoing scheduled evaluation of workflow and adjust as needed
  • Determine what data you will want to collect ongoing

TIP:  Actively seek to minimize disruption to the current workflow. Anticipate barriers and be prepared to address them. It is important to consider all perspectives when designing the workflow, including that of the person with diabetes, the support staff, and providers. You may want to include a patient representative to assist with the design, implementation, and evaluation of the workflow to ensure that you fully understand their perspective.

Commercial insurance and Medicaid plans vary regarding amount of coverage for personal CGM devices and their ongoing supplies.


Medicare will cover personal CGM if the following criteria are met:

  • The beneficiary has diabetes mellitus; and,
  • The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
  • Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-3) above are met; and,
  • Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

Step 4 Checklist:

  • Seek input from all team members regarding the design of the workflow
  • Define the workflow of an in-person visit from beginning to end

TIP:  You may be requested to do a peer-to-peer review to further determine the medical necessity for the personal CGM. It may be helpful to have a template prepared that includes details that you want to include in a review.

Defining the documentation and billing process before you begin will help ensure that all potential roadblocks are anticipated, identified, and addressed.

  • Educate staff on the billing codes to utilize for Personal CGM

Step 5 Checklist:

  • Identify the team member to be accountable for coordination of insurance benefits and requirements
  • Provide an in-service for staff on coding, billing, and documentation requirements for Personal CGM
  • Provide an in-service for staff about CGM remote monitoring visits that includes documentation and billing requirements
  • Identify team member(s) to perform ongoing documentation, coding, and billing audits of individuals in the program

TIP:  Mapping out the documentation and billing process before you begin will help to ensure that all involved staff understands the necessary codes to bill when there is a patient visit with a personal CGM to be evaluated.

Staff will need to be trained on the personal CGM program being offered in your practice. Training should cover an overview of the workflow, including patient selection, use of the device, providing education to the patient, diagnosis/coding/billing, documentation, download, and interpretation of results.

Step 6 Checklist:

  • Develop a protocol that identifies characteristics of individuals that would most likely benefit from Personal CGM
  • Set up vendor training sessions for all involved staff to learn about the different personal CGM devices and how to download information
  • Provide resources for staff about the different routes to obtain Personal CGM (how to pick up the product from the pharmacy or obtain from DME supplier)
  • Develop staff competencies that are role specific and identify a process to review and document their sklils on an ongoing basis
  • Set up provider training on program workflow and protocols, diagnosis/coding/billing, interpretation, and documentation of downloaded information
  • Plan for annual training refresher

TIP:  Providing thorough pre-implementation training will help ensure a smooth start to the program. Solicit staff feedback frequently during and after the training sessions. Consider recording the training sessions so that new staff in the future will have access to it.

Ensure that all team members are aware of their roles and responsibilities.

  • Proper staff preparation will make sure that the team is on board with the program and motivated to put in their best effort to help make it a success.

Step 7 Checklist:

  • Host a program launch kick-off event to review roles/responsibilities and provide a program overview
  • Identify staff ‘superusers’ who can serve as resources to others
  • Have vendor and IT available during implementation
  • Make device procedure reference materials and troubleshooting guides widely available
  • Provide a forum for staff to provide feedback and suggestions

TIP:  Keep an open communication line with the team members and involved staff. It is important that the team feels that this is a collective effort and that everyone’s feedback is equally important. You may want to try the program out with just a few people with personal CGM devices at first, as a test pliot. This will help to identify any process issues.

The Personal CGM Program will anticipate an upfront learning curve for the person with diabetes.

  • It is vitally important to provide initial and ongoing education about their personal CGM device

Step 8 Checklist:

  • Develop a handout for the person with diabetes that discusses how to get the most out of their Personal CGM. The power of data can help the person feel more in control of their diabetes and can facilitate a more collaborative approach with the healthcare team.
  • Provide initial training including a detailed education plan for the patient about their personal CGM device and ongoing training to help them maximize the use of their device
  • Identify procedure to provide ongoing support for a person using Personal CGM

TIP:  Make the person with diabetes the centerpiece of the program. Spend time up front on education and support to ensure their understanding of the process and goals of the program. Provide ongoing support as they continue their CGM journey.

You are now ready to try out your new program!

  • Solicit feedback and ideas from staff and patients throughout the implementation process
  • Start tracking success measures at program initiation

Step 9 Checklist:

  • Walk through the process from start to finish
  • Provide on-site technical and product support resources to staff during launch
  • Perform frequent check-ins with staff at this beginning phase of the program implementation
  • Schedule a weekly staff meeting to discuss how things are going
  • Start collecting any clinical and financial data that you will want to analyze ongoing now

TIP:  If possible, try to have some cushion in your staffing during this time. This will enable staff to take the time necessary to fully learn and practice the new procedures and processes. Communicate frequently with support staff to identify any challenges or obstacles to program success. Utilize vendor support and IT support to ensure a smooth implementation.

Program evaluation is an ongoing process.

  • Be thoughtful and quickly responsive to suggestions/ideas/feedback
  • Refer often to the metrics of program success that you have identified
  • Practice continuous quality improvement

Step 10 Checklist:

  • Gather staff feedback on a consistent basis
  • Survey the persons with diabetes that are being served by this program regarding their satisfaction
  • Analyze and evaluate clinical and financial data that you have collected
  • Compare diabetes outcomes post-Personal CGM Program to pre-program outcomes
  • If you are not meeting success metrics, reevaluate your program process and amend as necessary
  • If you are meeting success metrics, disseminate the results widely
  • Meet with the entire team to determine next steps. Is the program the right size? Does it have the right composition of staff? Is there reasonable access to the program?

TIP:  Establish a timeline for ongoing program evaluation. A program may not attain the expected measures of success in the first few rounds of evaluation. Staff will become more efficient with the program processes as time goes by. Ease of use will improve, and staff confidence and competence will show ongoing improvements as well.

Planning for the future of your Personal CGM program is a crucial component of a successful program.

  • What are the next steps for your program?
  • Do you want to establish a satellite location?
  • Do you want to start working with patients remotely?
  • Do you want to offer a Personal CGM support group or annual group education class geared to people who use personal CGM devices?
  • Do you want to share your program experience and lessons learned with other care teams?

Step 11 Checklist:

  • Hold a meeting with the entire team to discuss future goals for the program
  • Explore feasibility of the goals
  • Market the program to others that may wish to refer to your program

TIP:  Remember to include administration when planning for the future of the program.


References

This content has been adapted from the Association of Diabetes Care & Education Specialists, Professional Continuous Glucose Monitoring Implementation Playbook, and the Personal Continuous Glucose Monitoring Implementation Playbook. Playbooks are available for download at here.

Note: These Playbooks include Worksheet Resources that support these step-by-step processes.