EXECUTIVE SUMMARY

Chronic illness case management works better with optimal patient engagement. In one primary care provider practice’s experience, a diabetes care program has improved diabetic patients’ self-management.

• Lifetime Family Care uses a patient-focused approach.

• A dietitian/care manager helps patients improve their goals, working to ensure they are SMART: specific, measurable, achievable, relevant, and time-bound.

• Care plans are individualized and take into consideration the patient’s willingness to change.


Better engagement with patients is the key to success in chronic illness case management, according to a dietitian and care manager of patients with diabetes.

The Diabetes Care Program has successfully improved diabetic patients’ A1c testing rate, nephropathy monitoring, blood pressure control, and other self-management measures, says Rachel Brown, RD, MBA, IBCLC, dietitian and care manager for Lifetime Family Care in Warren, MI.

Lifetime Family Care, a small family practice, has helped diabetes patients improve their health and care management for several years, earning the practice a best overall diabetes practice award in 2016 by the Michigan Care Management Resource Center in Ann Arbor.

As part of its patient-focused approach, Lifetime Family Care sends patients surveys and reviews the results monthly, using the feedback to improve care. Also, employees participate in monthly training sessions about how to improve patient and practice team relationships.

Brown describes how the program works:

• Referrals and first call. Lifetime Family Care refers patients who might benefit from nutritional consulting to Brown.

“I contact patients via telephone and work with them to get any questions answered regarding nutrition and lowering their carbohydrate intake to lower their blood sugar,” Brown says.

Most calls range from 15 to 30 minutes and include a basic assessment of the patient’s nutrition, current medication, and lab results.

“I ask what they’re struggling with and then we develop a good plan for them with the ultimate goal of teaching them how to manage their own care,” she says.

For this first call, Brown helps patients come up with a simple goal for the near term. Although patients often say their goal is to lower their blood sugar, she helps them make sure it is a SMART goal: specific, measurable, achievable, relevant, and time-bound.

“One of my jobs is to get those goals more SMART, so they can set out to achieve what they want to do,” she says.

SMART goals might include these:

- “I will check my blood glucose three times per week.”

- “I will keep my doctor’s appointment.”

- “I will start exercising, walking for 10 minutes, four days a week.”

- “I will cut down on my soda intake, and I’ll drink more water every day, aiming for 60 ounces per day.”

- “I will take my medication every day as prescribed, refill, and call the office as needed.”

Brown covers as much information as she can on the first call. “If they’re overwhelmed, I schedule a weekly follow-up.”

• One-stop diabetes check-up. The primary care provider’s office makes it convenient for patients to undergo their annual diabetes exams at one location. Lab work, foot exams, and retinal eye exams can be performed, Brown says.

“We assist patients in the office to get those gaps taken care of,” she says.

• Patient education. Brown mails patients basic educational information regarding the do’s and don’ts of diabetes, healthy eating plates, the importance of eating three meals a day, limiting sugar and sweets, maintaining a healthy weight, controlling intake of carbohydrates, reducing high-fat foods, filling up with fiber, and the importance of exercise as it pertains to blood glucose control, Brown says.

“I mail out literature that verbalizes all of these points, so when I call back on the second visit, they have a paper in front of them and things make more sense,” she adds.

• Individualized plan. “I assess their understanding and intent to comply,” Brown says.

If patients’ lab work shows that their overall glucose levels are improving and their A1c is improving, then she knows they have a good grasp of what they need to do to improve their health.

The individualized care plans take into consideration each patient’s readiness to change.

“One of the hardest things is seeing where they’re at in readiness to change, readiness to move forward, and we try to meet them where they’re at,” Brown says.

“Something I do with every patient before hanging up is set a goal, clear boundaries, and SMART goals so they’ll know how to meet that goal.”

During each call, Brown discusses with patients how to meet the goal and whether they met the last session’s goal. If they have not met their goals, they look at what the barriers are and how to overcome them going forward.

If a patient is doing well with the last session’s goals, then Brown will suggest he or she make the goal a little more challenging, maybe working toward 15 minutes of exercise, four times a day. “We see what they’ve accomplished with the current goal and then see if they’re OK with that and then add more,” Brown says.

• Addressing barriers. “Sometimes, patients’ barriers may include transportation, funding, time management — and those are things I can help them with,” she says. “We do what we can to get them in touch with programs that help with transportation to doctor’s appointments and help with medication.”

Brown helps patients make connections to community health information, as needed.

“I spend maybe half an hour per patient doing that,” Brown says. “Some patients don’t have any social determinants of health affecting their health outcome.”

• Measuring outcomes. “We measure their A1c and blood pressure, and we’re looking for improvement across the board in all those metrics,” Brown says.

The case management program has shown the following improvements between 2016 scores and 2017 scores:

- A1c testing rate increased by 6.8 points;

- monitoring for nephropathy increased by 10.1 points;

- blood pressure control increased by 2.6 points;

- percent of days covered by statins increased by 8.1 points;

- percent of days covered by diabetic meds (all class) increased by 3.5 points.

A comparison of 2017 scores versus 2018 (through July 31, 2017) showed these results:

- retinal eye exams increased by 14.4 points;

- percent of days covered by statins increased by 27.4 points;

- percent of days covered by diabetic meds (all class) increased by 33.3 points.