Pilot study proves CM’s effectiveness

Program improved testing rates for sickest patients

Preliminary results of a special pilot diabetes study at Lovelace Health Systems in Albuquerque, NM, show that a significant number of patients have already experienced a notable decrease in their glycohemoglobin levels, indicative of improved blood glucose control.

Hospitalizations in the intervention group are infrequent, although there has been no comparison with controls at this point in the study. As important as these apparent improved clinical outcomes are, Vicki Mitchell, director of case management for Lovelace, says, "The most gratifying aspects of this study so far have been the positive feedback from patients and the significant improvement in the case managers’ practice skills and knowledge base in working with diabetes patients."

Mitchell reports that her department began working on its diabetes disease management-case management model in 1998. The department has had a long-standing interest in developing case management protocols to support implementation of the organization’s "Episodes of Care" disease management program. While the case managers had been providing traditional case management interventions to reinforce the physician plan of care, the staff recognized the difficulty of measuring case management outcomes within a routine practice framework. (See "Lovelace diabetes plan hikes testing rates," p. 19.)

The idea of developing specific disease protocols and implementing them in a research environment had tremendous appeal. A welcome first opportunity came when New York City-based Pfizer Corp. provided financial support for a six-month diabetes outcomes study.

In 1998, the Health Care Financing Admini stra tion (HCFA) sent out a request for proposal looking for two case management departments in the country to be demonstration sites — one in diabetes and one in congestive heart failure (CHF) — to assess the impact and cost-effectiveness of case management for Medicare fee-for-service beneficiaries. Lovelace submitted a proposal to HCFA for each project in September 1998. As the facility waited to hear about the awards, the case managers converted what they hoped would be a three-year HCFA project into a six-month pilot study, and they received their Pfizer grant for implementation of the pilot. The title of their pilot study is "The Impact of Case Management on Utilization and the Cost of Diabetes."

The pilot consisted of 50 intervention patients and 50 control patients. The selection criteria included:

• a diagnosis of diabetes;

• the presence of comorbidities;

• the highest-cost diabetes patients within the health care system.

"It’s hard to show change in a patient who is well-managed or who has mild or moderate diabetes," explains Mitchell. "We took the sickest patients and the highest utilizers."

The protocol team wrote a Diabetes Protocol Manual that was used as a handbook for the case managers’ training. "The manual has been used as a reference tool throughout the course of our study," says Mitchell. "The case managers’ training involved didactic presentations by an endocrin ologist, a diabetes educator, research staff, a psychologist with expertise in motivational training and behavioral techniques, and members of the case management protocol team."

Intervention patients were given pre- and post-study quality-of-life surveys, such as the SF-36 and the Diabetes 2.1, a quality-of-life tool customized for diabetics. They also received intensive case management through weekly case management interventions — home visits, clinic visits, or telemanagement.

"The case managers tracked their patients’ blood sugar levels, exercise, diet, standard lab work, and medication compliance," says Mitchell. "They also facilitated communication between the patients and their primary care physicians, and they coordinated visits with a diabetes educator when it was appropriate." The project’s short-term goals were to improve the patients’ understanding and self-management of their diabetes and to improve their overall quality of life. Long-term goals were to improve clinical outcomes and reduce unnecessary health care costs related to diabetes.

Intervention patients received a $10 grocery store gift certificate at the beginning, middle, and end of the study to encourage them to participate in the study.

Control patients received their usual medical care, which typically included seeing their doctors, seeing diabetes educators, and an occasional traditional case management intervention if they were referred for these services by the physician or other health care team member.

In December, Lovelace received notification that it had been awarded research grants to become a three-year demonstration site for both diabetes and CHF. "We’re very excited," says Mitchell, "and our pilot study has helped us to refine our protocol and to prepare for these larger projects. This type of rigorous study has provided insights that have helped us to fine-tune our practice techniques with diabetes patients. Though we hope to demonstrate the value of case management through the clinical, cost, and utilization outcome data that will be available later in 2000, we have already been impressed by the feedback that our patients have given us that indicate changes in their lifestyles and quality of life."

For more information, contact Vicki Mitchell, director, case management, Lovelace Medical Center, Albuquerque, NM. Telephone: (505) 262-3893. E-mail: vicki.mitchell@lovelace.com.