Plan offers wide range of diabetes programs
Targets people at risk for the disease
Since Optima Health began its Mission Health wellness and disease management program five years ago at a large employer group, 84% of the 450 participants with diabetes have taken their medication as ordered, compared with just 55% when the program began.
“We’ve also been able to demonstrate a return on investment when we compare the medical cost trend with the actual costs, taking into account the fact that the participants are aging every year,” says Karen Bray, RN, CDE, PhD, vice president, clinical care services for the health insurer based in Virginia Beach, VA.
Participants in the diabetes management program can receive incentives of up to $460 in their healthcare saving accounts if they meet the program requirements, which include seeing their physician regularly, taking their medication correctly, having all evidence-based tests such as a hemoglobin A1c, foot exams and eye exams, and talking to their nurse health coach at least quarterly.
In addition to the diabetes management program, the health plan offers education and support for people at risk of developing the disease. “We’ve grown away from a model focusing solely on people who have met utilization or cost thresholds because they already have a problem. Instead of focusing on the disease of diabetes, our disease management and case management programs focus on total population health, and diabetes is just one of the triggers,” Bray says.
Optima’s programs for employer groups are part of a wide range of programs the health insurer has developed on diabetes prevention and management. At one point, Optima placed diabetes case managers in some physician practices, but while the program was effective, there were limitations, Bray says. “Not all physician offices have space for a diabetes case manager, and there are not enough diabetes educators to go around,” she says.
Now the health plan has trained all of its case managers and disease managers on managing diabetes so they will know how to work with members with diabetes and what they can do to collaborate with physician practices to help their patients manage the disease. “As a health plan, we make it possible for physicians to develop innovative ways to manage diabetes in their patients,” she says.
The health plan has worked with physicians to educate its nurses and other staff on diabetes principals of care so they understand what to tell patients. In addition, the health plan reimburses physicians for group visits that focus on diabetes. “We’ve found that one of the best strategies for teaching people how to manage diabetes is to get them together with other people who have the same diabetes and collaborate on what to do,” she says.
The health plan has developed broad-based initiatives throughout the continuum of care and works with providers in the hospital as well as the community to educate them about diabetes best practices.
“A lot of people think of diabetes as a disease that is treated by specialists. There is a huge diabetic population and everybody can’t get access to an endocrinologist. The majority of people with diabetes get care from their primary care provider,” she says.
Optima Health regularly mines its data to identify members who could benefit from its health coaching program. In addition, physicians and the patients themselves often call about the program, she says.
A nurse case manager calls people referred to the program and conducts a complete assessment to identify not only diabetes and comorbidities, but to get a picture of the person’s general health and living situation. “We often find that people are not taking care of themselves because they are overwhelmed by other things in their life, like a child who is having trouble in school or a family member with a serious illness,” she says.
The nurse works with the patient to identify problems to work on and develop a care plan. “We build the plan around what the patient is willing to do, rather than what we think they need. We want people to be successful, but they are the ones who have to make it happen,” Bray says.
The nurse and the patient collaborate on setting goals that are achievable. “We encourage people to take small steps rather than trying to do everything at once, which just sets them up for failure,” she says. For instance, instead of going to the gym every day, the nurse case manager will suggest that they start by going one day a week. “Each time they achieve something, it creates rapport with the coach,” she says.
Once the plan is in place, the case manager follows up at time intervals agreed upon by the patient. “We call as often as necessary, but it is driven by the individuals. We work on creating a relationship. We don’t want the calls to seem like a burden. Otherwise, they won’t answer the phone,” she says. During the calls, the case manager looks at barriers to achieving the goals and work with the patients to overcome them. For instance, if the weather is bad, the case manager suggests walking in the mall.
If the case managers find problems that need the attention of a physician, they contact the patient’s primary care provider. If patients can’t afford their medication, they look for resources in the community or from the drug manufacturer or discuss the possibility of lower-cost, higher-quality alternative medications with the provider.