Diabetes program enters second stage

MCO finds it’s best to walk before you run

The benefits of disease management programs for utilization and medical cost reductions now are widely accepted. However, once those initial objectives are met, it’s time to switch your focus from appropriate allocation of services to improving the overall health and quality of life for plan members.

"Discovering and applying effective ways to care for our members with chronic illness results in productive individuals who enjoy good quality of life and, ultimately, in lower health care costs. Since those goals are aligned with those of corporate and government purchasers, they are also good business," says Robert L. Crocker, MD, national medical director of care management services for UNICARE in Thousand Oaks, CA.

As the managed care industry matures, health plans must move beyond utilization trends to a best outcomes focus, notes Crocker. "As organizations, we must shift our focus to best outcomes. That’s the direction UNICARE is heading, and I firmly believe it’s where the entire industry must move. You reach a point where you’ve done all you can with controlling overuse and misuse of health care services, and there is a point of diminishing returns. Disease management is a natural outgrowth of the maturation of the managed care industry, and the shift from measurement and improvement of utilization trends to measurement and improvement of quality of life and clinical indicators is the natural maturation of a disease management program."

To meet the challenge of controlling one chronic disease, diabetes, UNICARE conducted a pilot program involving 35 patients from spring 1997 to spring 1998. The goal was to test whether combining early identification, direct intervention, personal contact, member education, and a team approach among providers — all based on best treatment practice guidelines — could result in improved health.

Encouraging the use of appropriate services led to a dramatic decrease in the need for acute inpatient care. Participants saw their physicians and used other outpatient services 250% more often than they did before enrolling in the program. Consequently, hospital admissions declined by nearly 40%. There was nearly a 50% reduction in overall hospital bed days and a 17% decrease in hospital length of stay per participant.

Medical professionals involved in the program were not entirely surprised by these results, says Crocker. "The stage had been set for favorable outcomes. Patients were educated and motivated, they were cared for according to the best guidelines we now have for treating diabetes, and they benefited from continual personal contact with medical professionals."

Benefits of education are far-ranging

The results of the pilot diabetes management program validate UNICARE’s "member first" philosophy, he says. "The benefits of taking an active role in one’s health care are far-ranging. As caregivers, we have seen that members with chronic conditions who are empowered through education and commitment to a treatment plan are less likely to feel they are victims’ of their disease. And they are less likely to experience the feelings of helplessness that follow a serious diagnosis."

While the success of the disease management program is very good news to individuals living with chronic diseases, it also is significant to UNICARE’s employer customers, Crocker says. "A chronic condition such as diabetes or asthma can take its toll in lost work time and underperformance. A successful disease management program provides the needed support for an individual with a chronic illness to continue contributing on the job and in the rest of his or her life," he notes, adding that UNICARE’s diabetes management program now includes more than 400 patients.

The program began with a crucial step: early identification. UNICARE case managers, using a selective screening process, identified members whose diabetes was not well controlled, placing them at risk of serious complications. These at-risk patients were identified through claims and pharmacy benefit data or through calls requesting hospitalization or home care. A sure sign that these members needed help managing their disease was that they had high rates of hospital admission.

Outreach program identifies candidates

Once candidates for the program were identified, a systematic outreach process was set in motion. A letter was sent to each patient stating that, based on the patient’s specific diagnoses, he or she was eligible to participate in the diabetes management program. The letter outlined how patients could benefit from services available through the program, whose goal was to improve their health and keep them feeling their best.

UNICARE case managers subsequently contacted patients by phone to perform a detailed evaluation. "We learned when they were diagnosed with diabetes what other diagnoses they had and the extent of their knowledge about their diabetes. The assessment also pinpointed their level of diabetes control, understanding of their current treatment plan and individual circumstances that could be a barrier to better health, such as home or work situations," says Crocker. With the participant’s permission, case managers contacted the treating physician to confirm the treatment plan and obtain information about the patient’s overall control of their diabetes.

Each patient then received educational materials that served as key learning tools and a means for UNICARE nurses to determine the patients’ level of understanding of their disease. Each patient received a booklet on Type 1 or Type 2 diabetes, as appropriate. In addition, patients received a booklet on nutrition, if their assessment indicated they needed help in learning to eat correctly.

The booklets, produced by a commercial publisher of patient education materials, were written in simple terms and included illustrations, Crocker says. The materials explained the disease and its treatment and included tips on ways to keep it under control, such as exercise and diet.

Nurses followed up with members to determine whether patients had read and understood these materials. Nurses assisted patients with literacy problems to comprehend the concepts, and the nurses referred patients to outpatient diabetes education centers for further help when necessary.

UNICARE case managers then worked directly with members and their caregivers — physicians, nurses, diabetes educators, and other professionals — to ensure that best practice guidelines were followed. The caregiver team stressed the importance of a key method of diabetes control: the quarterly HgbA1C blood test recommended by the American Diabetes Association in Alexandria, VA. The test demonstrates the patient’s average blood sugar control for the previous three months. Because the test is unfamiliar not only to many patients, but also to some primary care providers, UNICARE nurse educators contacted physicians to remind them of the need to draw blood from these patients quarterly to perform the test.

UNICARE nurse case managers also facilitated access to education and support. They suggested resources convenient to patients such as outpatient diabetes education centers, diabetes clinics, or support groups. If some patients preferred not to visit a diabetes education center, then our nurses provided one-on-one education and information.

Nurses put patients in control

While physicians directed care and examined each member regularly, nurses encouraged and motivated patients to take control of their own health and manage their condition. For example, patients were instructed on how to examine their feet daily for areas of redness, discoloration, and swelling; how to trim their toenails to avoid cutting too close and causing ingrown toenails and infections; and how to choose proper footwear. Since many diabetics lose parts of their feet and limbs because they don’t examine their feet every day, these careful, detailed instructions helped prevent serious complications.

Continual support and ongoing follow-up, based on each patient’s symptoms and individ -ual need for education, resulted in patients who understood and actively pursued a proven regimen that enhanced their health and well-being. An important aspect of the program is that it supported the work of treating physicians, who found themselves caring for better-educated, more compliant and motivated patients, says Crocker.

"The interesting thing that case managers found as they acted as intermediaries between the patients and their physicians is that often patients are told A’ but hear B,’" he says. "Case managers have a wonderful opportunity to help participants cross that bridge. Our case managers would call providers and say, Your patient has enrolled in our program and tells me this is what you’ve instructed them.’ Many times, physicians would immediately say, That’s not what I meant at all.’ The case managers would then contact the patient and clarify the physician’s orders."

As UNICARE’s diabetes management program moves forward — enrollment has increased from 35 to 400 — the next phase is to measure utilization data as well as quality of life and clinical indicators. Measurements being gathered from participants include the following:

• HgbA1C levels;

• compliance with treatment plans;

• self-reported days lost from work or school;

• other quality-of-life indicators such as self-reported health and well-being.

"Some conditions, such as asthma, have immediate short-term returns that can be easily measured. For other conditions, such as diabetes, it’s more a matter of preventing long-term complications. In the short-term, we often see a temporary increase in outpatient services as we encourage regular testing and examinations. The real returns come later. That’s the challenge, and that’s the balance," says Crocker. "You have to walk before you run, but now we must move beyond utilization measurement and look in other areas for appropriate outcomes that help us monitor our success. It’s a challenge, but one that those of us developing disease management programs must be willing to accept."