Proactive CM improves outcomes for diabetics

Focus is on prevention of acute episodes

The Diabetes Treatment Centers of America (DTCA) in Nashville, TN, successfully reduced hospital admission rates for diabetic patients enrolled in its diabetes management program to 67.3% below the national average for diabetics nationwide. Early last year, DTCA launched a diabetes management program for payers it hopes will yield similar results for patients before they enter the hospital.

The DTCA diabetes management program for payers kicks in with proactive case management the moment a member receives a diabetes diagnosis. "We don’t wait for the triggers which normally activate intervention by a payer case manager, such as a hospital admission. Every member with diabetes is part of the program and receives a basic level of intervention," notes Janet Calhoun, RD, CDE, senior director of clinical operations for DTCA. The first step DTCA takes is an identification process. "We use the payer’s historical claims data and run it through a program we’ve developed to identify people with diabetes," she explains. "Right now, we’ve taken a very conservative approach and only identify those members who have submitted a claim for diabetes as a primary diagnosis, or a diabetes related event, such as diabetic retinopathy," Calhoun adds.

DTCA’s information system then uses the payer’s historical claims data for the previous year to stratify diabetic members into three levels based on cost. "We run several reports with the data to look at high cost members, high cost facilities, and high cost providers," says Calhoun.

Before a DTCA diabetes care coordinator contacts a member directly, DTCA contacts the member’s primary care physician to confirm the diabetes diagnosis. "We actually take two steps at once. We confirm the diagnosis, but we also take the opportunity to market the program to the physician at the same time," says Calhoun. "We want to make it clear that the diabetes management program is designed to support primary care, not replace it. We also clarify that we do not send patients to a subset of physicians. Members stay with their own primary care physician. Our job is to support that physician to care for the member as long as possible," she adds.

Once members have been identified and their diagnosis confirmed by their primary care physician, DTCA collects clinical data that helps set the level of intervention members receive from care coordinators, explains Calhoun. Specifically, DTCA focuses on clinical parameters that indicate a member is at risk for high cost diabetic complications. The data is gathered through the physician’s office, historical data, and pharmacy data supplied by the payer. Parameters DTCA collects for each diabetic member include:

• blood pressure;

• history of microvascular disease;

• pregnancy;

• personal member perception of health status;

• hemoglobin A1C level.

"Studies indicate that A1C levels are the best indicator of a person’s risk for developing diabetic complications," notes Calhoun. "Research supports the theory that the higher the A1C level the greater the risk of complication."

After the clinical parameters are collected, they are run through a computerized stratification model which places members into three population levels. "The stratification levels help care coordinators set the degree of intervention each member receives. The system helps guide care coordinator decision-making," says Calhoun, adding that members may shift from one level to another more than once. Stratification levels include:

Level 1: These members are at home and healthy. Their diabetes is currently well-managed. Care coordinators contact them on a quarterly basis. "These members receive an educational newsletter, announcements of diabetes education seminars, reminders about routine annual examinations, and other interactions as determined by the care coordinator, such as birthday cards," notes Calhoun. "If the member is sent a reminder for an annual eye exam, and we don’t get those eye exam results back, the care coordinator calls the member to make sure the exam is scheduled," she adds. "We follow a set a national standards which we feel the entire diabetic population should meet. Part of our proactive intervention approach is to use those standards of care to identify an early trend toward increasing severity."

Level 2: These members are diabetics with low intensity health care needs of long duration, or high intensity health care needs of short duration. "Perhaps, their blood pressure is high and that puts them into level 2. We know we may never get their blood pressure down to normal, but we want to keep it at a reasonable level," explains Calhoun. "Members may also have an acute illness of short duration that left untreated could lead to clinical complications, such as an abscess tooth. We know that if we intervene, we can prevent the use of a lot of health care resources," she adds. In addition to the basic Level 1 interventions, care coordinators make at least monthly telephone contact with Level 2 members.

Level 3: These members are diabetics with very high intensity health care needs. "The member may be pregnant and in the hospital," says Calhoun. "And, this is where, typically, the payer case manager steps in to handle the care coordination needs, and our care coordinator becomes an additional resource, or member of the health care team, that the payer case manager can rely on," she adds. "At this point, we often focus on the true diabetes metabolic management so that it doesn’t acerbate whatever the primary condition is," Calhoun notes.

The last step in the diabetes management program is monitoring the progress of members. "We track how the population as a whole is moving between stratification levels. We also look closely at what seems to determine those movements from one level to the other," explains Calhoun.

Preliminary results for the first 104 patients enrolled in the payer program found that members had a 7% reduction in A1C levels during their first 90 days in the DTCA program, adds Robert E. Stone, MBA, executive vice president of DTCA. In addition, the number of members stratified into level 3 dropped from 49% to 32% between May and August 1996 for the same 104 patients, he adds. "We’re making a leap of faith at this point that there is a corresponding reduction in medical costs. In fact, we’re sure there is reduced cost associated with improved health status, we just can’t quantify it, yet," Stone concludes.

[Editor’s note: For more information about the diabetes management program, contact: Robert Stone, DTCA, 1 Burton Hills Blvd,. Nashville, TN 37215. Telephone: (615)665-1133. For more information on DTCA’s outcomes study, see Case Management Advisor, December 1996, p. 171.]