Program targets diabetics with highest utilization

Frequent interventions for sickest members

When it comes to a common disease such as diabetes, "we can’t manage the universe," Giavanna Ernandes, RN, MSN, APNC, asserts.

"My philosophy is that, although you can’t reach out to everybody, you can make a difference for the sickest members," adds Ernandes, team leader for disease management at Horizon/Mercy, a Trenton, NJ, health plan for the publicly insured.

Horizon/Mercy has had a population-based diabetes program in its quality department for years but realized that it was impossible to closely manage all 10,000 diabetics in the plan.

"We moved the program to case management and clinical operations to expand it and make it more clinically intensive. We’re operating on a disease management model and are managing those who need the most help rather than just taking care of the entire population," says Pamela Persichilli, RNC, director of clinical operations for Horizon/Mercy.

The diabetes program started with the highest utilizers of health care resources based on hospital admissions, emergency department visits, and pharmacy claims.

By researching the data, they identified members who had more than $1,000 in claims in a year. In the first five months of the program, 803 members were enrolled.

When a member with diabetes is identified, the case managers conduct a risk assessment and health assessment to determine which ones should be targeted for the program.

The members who are not at highest risk receive population-based disease management that includes health education and targeted mailings, such as reminders to get a flu shot.

The case managers focus on the top 20% of the sickest patients, providing them with visiting nurse services, transportation to physician visits, and intensive health education.

"We focus on the sickest of the sick. We can’t take care of the entire population. We have a lot of members who are doing well and don’t need our help," Ernandes says.

The case managers make outreach calls to the members, giving them basic diabetic education and providing glucometers or other supplies if the members need them.

If a member has frequent admissions and is not being seen by an endocrinologist, the case managers call the primary care physician and suggest a referral.

The case managers review members’ laboratory reports, looking especially for elevated hemoglobin A1C levels.

"We call everyone with a level over a 7 because this means the member has not been maintaining glycemic control," Ernandes says.

The case managers educate the members about foot care, nutrition, and the importance of complying with their prescribed medications and regimen.

They make sure they have a glucometer and are seeing a physician who can help them manage their disease.

If the members don’t understand how to check their blood sugar level or give themselves insulin, the case managers arrange for the visiting nurse service to help them. The case managers tell the members that the elevated levels will result in hospital admissions down the road.

They monitor pharmacy claims to make sure patients are filling their prescriptions.

"With diabetes, we like to see more claims. It shows us that they are taking their medication, and that’s a good thing. Higher pharmacy claims mean that inpatient admissions should be lower down the road," Persichilli says.

Because Horizon/Mercy’s members are publicly insured, they are at high risk because of social and environment issues in addition to the disease. "Diabetes is a complicated disease process. Most of our patients have cardiac problems and other comorbidies as well," Ernandes says.

The program uses the American Diabetes Asso-ciation guidelines as the basis for its program.

"We needed to take a more targeted, more consistent, almost regimented approach to getting everybody involved," Persichilli says, adding, "education is great, but sometimes you need interventions to make education work."

Persichilli credits the administration of Horizon/Mercy for recognizing the return on investment for their disease management programs.

"In the early days, we didn’t have the data, but now the data are there to support case management and disease management as affecting the bottom line. It’s not just something nice to do or something to promote your health plan. It produces real results, better outcomes, and better member satisfaction," she says.