Success for intensive nurse case management

Patients learn at their own pace

Prudential’s Center for Health Care Research has already discovered that investing time and attention to patient education yields medical benefits for members of its HMO. Now researchers expect they will find it is also a cost-effective means of disease management. Furthermore, they hope to be able to devise a similar education model for less-structured managed care settings.

The study published in the Annals of Internal Medicine was part of Prudential’s quest for "simple low-cost methods translating guidelines into clinical care" that involve less of the relatively expensive time of a physician and more of the comparatively lower cost time of nurses and other clinicians.

Evaluating impact and logistics

The 12-month randomized trial involved 137 members of Prudential’s Jacksonville (FL) Health Care Group HMO (17 with Type I and 121 with Type II) and compared a nurse case management model with usual diabetes management in a primary care setting.

"It was a standard benefit, so that program was contracted by Prudential," says Robert Aubert, PhD, senior health care analyst at the Prudential Center for Health Care Research in Atlanta. "We’ve done this in San Antonio, also in a group model HMO. What we are looking at currently is to evaluate potential impact and the logistics of doing this in other network IPA-type health care delivery settings."

Jacksonville patients were ineligible if they had a recent HBA1c of less than 7%, uncontrolled hypertension, unstable angina, myocardial infarction, two or more episodes of seizures, documented alcoholism or drug abuse, late-stage complications of diabetes, or were pregnant.

The results: Type II patients in the nurse case management model experienced a mean decrease in HbA1c of 1.7% (from 9.0% to 7.3% after 12 months) and 43 ml/dL in fasting glucose levels, compared to a .6% decrease in HBA1c (8.9% at baseline compared to 8.3% after 12 months), and 15 ml/dL decrease in fasting glucose for the usual care group.

The results held true for Type I diabetics in the nurse management group, who experienced a 1.2% decrease in HbA1c compared to .2% in the usual care group.

Researchers found no significant differences between the two groups in terms of blood pressure, serum cholesterol, and triglyceride levels or body weight, although the intensive management group had fewer members of ethnic minorities, more smokers, and more insulin-treated patients.

"During the first three months, the patients just need to be titrated, educated, and have somebody giving them some attention," says Janice Waters, RN, diabetes disease management specialist with Prudential Center for Health Care Research in Jacksonville, and Atlanta. "I really think that first three months is very critical in an intensive management program like this."

Patients in Prudential’s program are enrolled in a five-week 12-hour hospital-based diabetes education program. In total, they receive more than four hours of individual counseling by program staff and hospital staff, including a nurse case manager, dietitians, and exercise therapists — and they get more time if they need it. They also receive group education sessions and can avail themselves of a wide variety of a published materials and videotapes.

Goal of patient responsibility

All patients in the hospital-based diabetes education program received counseling in nutrition, exercise, blood glucose monitoring, medication and insulin, psychosocial adjustments, stress management, acute and chronic complications, and optimal health habits.

The intensive three-month nurse case management program is designed to bring patients to the point of responsible self-management in that time frame. The curriculum was developed by a multidisciplinary team, which included endocrinology, family medicine, nursing, pharmacy, health services research, and epidemiology.

After an initial assessment by the nurse manager, patients were placed on a glucose monitoring schedule, asked to keep a log, and scheduled for a follow-up with the nurse two weeks later.

At the follow-up visit, patients were given medication adjustments, if necessary, and assisted in meal planning and exercise reinforcement. In addition, patients on insulin received weekly telephone calls. All others received a telephone call from the nurse every two weeks. And the nurse manager met with the physician or endocrinologist every two weeks to review the patient’s progress.

Aubert says researchers learned that most of the change in terms of glycemic control happen in the first three to six months, "So in terms of implementing the program, we are looking to try to do that intensive management part of three to six months and then try to roll people into a maintenance phase where there is less frequent contact."

Waters says flexibility is built into the program. "Not everyone learns at the same pace. Shock and denial are the first things that most people experience with a new diagnosis. That’s a health care professional’s call. Maybe this person needs a little bit more reinforcement or more calls or some individual time."

Some younger patients lost to follow-up

The study also showed a significant loss of patients to follow-up in both groups, the majority of them between 18 and 44 years old, which lost 11 of the 14 members of the intervention group.

Aubert says, "We may need to be a little more flexible, not as intensive. We also need to analyze data a little more. It could be that we just had more people change health plans who happened to be in nurse case management and were younger. The younger population tends to be more of a challenge in a lot of ways."

Waters adds, "I think the Type Is who have had diabetes for a long time require just a little bit more attention. For a younger person’s active lifestyle, sometimes it is not easy to be quite so rigid."

She notes there were no pump patients in the program and says she has recommended it to several younger more active patients because "it allows for more flexibility as far as the injection and the convenience."

Prudential Health Care is delving more deeply into the data generated by the Jacksonville study and hopes to release results soon about cost-effectiveness and the translatability of the program to less-structured health care programs.

For more information, contact: Ronald Aubert, PhD, senior health care analyst, Prudential Center for Health Care Research, Atlanta. Telephone: (770) 801-7880. E-mail: