Health plan moves diabetes management in-house

Care managers work with members at highest risk

After four years of positive experiences with a national disease management vendor, Fallon Community Health Plan in Worcester, MA, decided it would be more beneficial to members and providers if the diabetes management program was transitioned in-house.

The health plan chose an outside vendor when it started its diabetes management program in order to get the program under way quickly, says Wally Mlynaryk, MHA, director of disease management for the health plan.

“They definitely did have a positive impact on our program, not only in terms of decreasing resource consumption by members but also in improving the clinical parameters as gauged by HEDIS [Health Plan Employer Data and Information Set] figures,” he says.

Fallon Community Health Plan decided to bring the program in-house to give the program a local focus. Care managers are assigned to specific clinic sites throughout the health plan’s service area so that the related physician group has a single point of contact for its enrolled members.

Under the vendor’s program, physicians might receive phone calls from several different care managers, Mlynaryk says.

“It gives the providers an opportunity to talk to one person about all of their patients. They have one person to call if they have questions about the program or want help in maximizing the benefits of the program,” he says.

Fallon Community Health Plan’s diabetes management program includes care for both high-risk and low-risk members with diabetes.

Among the 13,000 diabetics covered by Fallon Community Health Plan, about 3,000 have been assigned to the high-risk subset. High-risk members typically are not managing their condition and are regularly telephoned by a care manager who monitors, educates, and supports the patient.

The health plan mines its claims data for members who have the potential to have complications of diabetes in the future. Risk factors the plan considers include hemoglobin A1C levels, creatinine levels, and past utilization history.

“These are strong predictors of future utilization for the diabetic population,” Mlynaryk says.

The health plan monitors lab values of members monthly. If a member’s A1C levels and creatinine levels are stable, he or she may be moved to a lower category or moved into the high-risk management program.

Members who are not in the high-risk population receive a quarterly educational newsletter created by the care management staff.

The diabetes team at Fallon Community Health Plan is working to develop a group follow-up program that would allow members to meet other members enrolled with the program as well as have a face-to-face meeting with their care manager.

It took the staff at Fallon Community Health Plan about a year of planning to make the switch from using a vendor to handling disease management in-house.

The plan already had established an Internet data registry for its other disease management programs and was able to include diabetes data in the registry fairly quickly, Mlynaryk says.

“We were able to take the same snapshot of the platform and modify it for diabetes,” Mlynaryk says.

The vendor had established a high-risk group, some of whom did not meet the criteria set by Fallon Community Health Plan for its high-risk group.

When the program started, those members received letters notifying them of the changes in the program and telling them that even if they did not meet the new high-risk criteria, they still would be monitored.

The health plan visited providers and told them the rationale for moving the program in-house and the benefits the new program would provide. Physicians also received a letter describing the new program.

When a member is referred to the high-risk program, whether by the health plan’s stratification process or a direct referral, the plan gets the approval of the primary care provider before starting the disease management program and gives the member an opportunity to opt out.

A few members have refused to participate, Mlynaryk adds.

“Since we’re look at a high-risk group, we use a combination of education and training. The real thrust is to try to get the members to check their blood sugars at home,” says Janice Betz, RN, senior clinical manager at Diabetes Care.

The care managers have rough guidelines for frequency of calls and often take their cues from the members as to how often to call, she says.

Members could get a call as frequently as weekly or as infrequently as quarterly.

“Some have a lot going on and don’t want to be called every week. We will negotiate on how often we call,” Betz adds.

The care manager takes into consideration how long the member has had diabetes and assesses his or her knowledge of the disease to decide if the member needs a full-blown educational program.

If so, he or she is referred to the diabetic education programs, a diabetes nutrition program, or both.

The diabetes program’s nurse care managers also address comorbidities, such as asthma or congestive heart failure, Betz says.