CM results in lower blood sugar, cholesterol levels

Program is tailored to meet individual goals, needs

A case management program for diabetes has resulted in a steady drop in hemoglobin A1C levels and cholesterol levels among members of ConnectiCare, a regional HMO based in Farmington, CT.

The program was developed in 1998 to address the specific needs of adult members with a diagnosis of diabetes, according to Lori Pennito, RN, program coordinator for the heart and diabetes program at ConnectiCare.

The program follows the goals and guidelines of the American Diabetes Association and aims to improve the health outcomes and quality of life for members with diabetes, helping them learn to manage their disease.

The percentage of members whose A1C levels indicate that diabetes is out of control has dropped from 37.5% in 2000 to 23.4% in 2005. At the same time, the percentage of members with diabetes with LDL cholesterol levels less than 130 mg/dl has improved from 36% in 1999 to 70.3% in 2005, the last year for which statistics are available.

ConnectiCare was one of the first HMOs in the nation to receive NCQA accreditation for its disease management program.

The health plan uses claims data to identify members with diabetes and laboratory data to identify those who are at highest risk.

Initially, case managers coordinated the care for all members with a hemoglobin A1C of 9 or greater. Since the program began, overall A1C levels have dropped to the point that the high-risk member outreach program targets members with a level of 8.5 and above.

When a member is identified as being at risk, a trained program assistant calls the member and introduces him or her to the program, following a script that includes several opportunities for the member to be warm-transferred to a nurse if the member wants more information on the program.

"Among the inherent challenges in any disease management program are getting in touch with the members and getting buy-in from them. It helps to have a brief introduction to the program, to verify the demographics, and to be able to transfer the call to the nurse case manager," Pennito says.

Using the program assistants to do the outbound calls was a process that evolved over time as the health plan looked for the best ways to engage members in the program, Pennito says.

Initially, the case managers were making the outbound calls, but they were spending too much time on the telephone trying to reach the member.

"It was not the best use of a professional's time," she adds.

When the health plan began using trained program assistants to do the outbound calls, enrollment in the program increased 23%.

When the program assistant locates a member, he or she introduces the program and either warm-transfers the member to a case manager or sets a time for a call from a case manager in a day or two.

The case manager conducts an intake assessment that includes an overall picture of the member's state of health, his or her knowledge of the disease, and how he or she is trying to keep it under control.

"The case managers spend a lot of time building relationships and getting an idea of the member's overall knowledge of the disease and what they should be doing," Pennito explains.

The case manager typically will arrange to call the member within a week or so to follow up.

"Case management is more intense in the beginning for several reasons. We want to make the member feel like they are a part of the program, and we have found that it is more effective to break up the educational component into smaller pieces so we don't keep the members on the telephone for long periods of time. The follow-up calls also reinforce the teaching," she says.

The case managers in the program are specifically trained in managing the care of diabetics. They do not use a script but proceed the way they feel will work best with each individual member.

"The plan is based on the nurse's expertise and what the member is willing to do," she says.

The case managers have a frank discussion with the members about the severity of the illness and what can happen if it isn't under control, she adds. They follow up on laboratory tests and other data.

"We are looking for objective data that the members are making some lifestyle changes, such as more desirable results from blood tests," she says.

How often a case manager makes follow-up calls depends on the members, what issues they are struggling with, and what goals they are trying to reach. It may be monthly, quarterly, or more frequently, depending on each individual's needs.

For instance, if they are trying to modify their diet, the case manager may call them frequently to make sure they are doing so, she says.

Members stay in the program until they decide to opt out or the case manager feels they have exhausted the benefits of the program.

One of the key goals of the program is to reinforce the physician's plan of care. The case manager does an assessment of what the doctor has prescribed, including medication, self-monitoring of blood sugar, diet, and exercise.

"They get a feel for what the members are actually doing and reinforce what the doctor has told them to do," she says.

The case managers are on the lookout for gaps in care and alert the member's primary care physician when recommended treatment regimes or tests have not taken place.

"Depending on what the issue is, the case managers will write or call the physician, highlighting the gaps in care, based on evidence-based guidelines," she says.

ConnectiCare sends out a quarterly report to physicians that includes laboratory reports on lipid levels and blood sugar levels.

If a member has a hemoglobin A1C level of 7 or more or an LDL cholesterol level of 100 or higher, the primary care physician gets an individual report.