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When Lovelace Clinic Foundation and Lovelace Health System’s case management department jointly initiated a pilot project on diabetes three years ago, they wanted to find out whether intensive case management of high-cost health plan members with diabetes had an impact on key health outcomes and on costs.
The early results are that it can, says Margaret Gunter, PhD, who heads the Lovelace Clinic Foundation, a nonprofit health research institute closely affiliated with Lovelace Health Systems, a large integrated system based in Albuquerque, NM.
Gunter says the pilot, sponsored by the Centers for Medicare and Medicaid Services (CMS), also showed improved guideline compliance among patients as well as improved knowledge of guidelines by case managers. Referrals to diet counseling improved, along with improved glucose control. In addition to decreased hospital and emergency department costs, there was clear evidence of improved physical function and improved quality of life among patients with diabetes, she reports.
The pilot has paved the way for the actual demonstrations, and its design and methods hold important lessons for case managers struggling to contain costs associated with diabetes.
According to Gunter, the first objective was to demonstrate that case management makes a difference in quality of care, outcomes, and costs. The second objective was the creation of an actual diabetes-specific case management protocol for the proactive management of the patients. "We wanted to pilot test it and see if it made sense and to work out some of the bugs," she reports. Finally, Gunter and her colleagues wanted to assess the feasibility of providing standardized case management services that integrated both nurses and social workers.
The pilot’s data sources included a relational database or electronic administrative database that contained inpatient and outpatient claims. Patients also filled out health status questionnaires, and case managers collected information. "That gives us an ability to look at the impact of disease management and case management programs on health care utilization," explains Gunter.
Using this electronic database, the pilot randomly selected 160 patients using ICD-9 codes. "We looked at all of the costs because we know diabetes patients usually don’t just have diabetes," she says. "It is other things, including cardiac conditions, that drive their costs up, so we looked at the most costly quarter of all patients that had diabetes." Patients were stratified by age and cost and then randomly assigned to either full case management or control, she adds.
Gunter warns that getting people with a lot of expertise and practice in implementing case management to try something very specialized is no easy task. To address that, the team that was responsible for the pilot initiated case management training and staff preparation. The most effective tool was asking specialists to come in and talk to the staff, she reports. For example, endocrinologists explained various aspects of diabetes, and a nurse practitioner who acts as a diabetes educator explained her role in the process.
The team wanted to make sure the training was specific to diabetes as well as some overflow on other diseases, Gunter says. To accomplish that, it developed a checklist for case managers to use every time they had contact with the patient. It also developed reference material as well as "motivation interviewing tools" that looked at the pros and cons of behavior change and the obstacles to behavior change.
Among the initial tasks, the pilot had to establish informed consent, identify key measures, develop instruments, and perform a human subject review. In order to recruit patients, the pilot team developed a baseline interview with data collection. "We wanted to identify a treatment plan that we could go over with the physician," says Zandra Rise, RN, a specialty case manager in the cardiology and pulmonary departments at Lovelace.
Baseline interviewing of patients included typical elements that most hospitals use in assessment but utilized an electronic system. By performing the initial review of all medical records that were electronically available, the case manager attained a general overview of the patient’s medical status. When the patient came in for the initial assessment, the case manager already knew the weak areas of management and could start to steer patients toward making changes, Rise says.
The team also wanted to gauge how adherent the system was to the episodes of care protocol, such as whether the laboratory tests, eye exams, and podiatry care were done properly and whether the diabetes educators were involved. It also looked at use of prescription drugs, over-the-counter drugs, and alternative medications and other dietary supplements.
The pilot also included a clinic visit that involved the patient, the case manager, and family members. "What we wanted to focus on is how [peoplr are] going to absorb the information," explains Rise. "Are they going to be incentivized by fear or encouragement?" The pilot also looked at the patients’ environment, including an inventory of food in their home and a list of restaurants they visit. It also helped determine if they needed a referral to cardiac rehabilitation, pulmonary rehabilitation, or simply an exercise area to continue to provide safe behavior changes, she says.
Rise says the pilot sought to individualize the treatment plan. "We put together a dictation of the treatment plan on our electronic system so that every provider had a copy of what we were working on," she reports. That way, each provider who had contact with the patient knew the game plan and could provide support in the areas that were specific to his or her specialty.
The pilot team also sought to convert all the goals that patients established with the case managers into a numerical system. "If it was physical activity, we knew that a patient was going from a 500 calorie exercise week to a 1,000 calorie exercise week," she explains. "We also wanted to quantify the nutritional plan and quantify any changes into a numerical factor so people could see what they were doing."
Ongoing monitoring included a weekly contact as well as a six-month review. "We definitely found that patients appreciated reinforcement in their behavior changes," says Rise. "Patients may not have met their goal, but maybe they were 50% there, and it was useful for them to look at where they started and where they are now."
When patients were terminated from the study, Rise says, many expressed a desire to continue the program. At termination, team members attempted to determine what the patient had learned from the study and what areas they wanted more help with.
"We did a satisfaction survey with patients, and we did a feedback session with our case managers to identify what it is that they wanted," she explains.
Under the pilot, Gunter says the average hemoglobin UNC went from 7.7 to 7.4. Equally importantly, 70% of all the patients showed some decrease in hemoglobin A1C. "That was again a clinical measurement that was really important to us," she says.
Inpatient costs were cut approximately in half, from $2,171 per patient to $1,113. However, Gunter points out that reducing the costs of a few very costly patients can skew results among a limited numbers of patients. Some outpatient costs went up, but that is to be expected when people are coming in for services that they have not been getting, Gunter says. "We hope that will keep them out of the emergency room and the hospital," she explains.
"These cost reductions would probably not be enough to pay for the costs of case management," says Gunter. On the other hand, she notes that the first six-month period is the most intensive time for case management, and if these patients were maintained over a longer period of time, the results could be far more significant. "We hope to do that in the upcoming [CMS] projects," she says.
She says the most significant learning point derived from case managers was that they wanted more supervision. "They wanted someone who could coach them as far as looking at all of the data."
They also wanted clarification on the role of the case manager, Gunter adds. Some of the case managers felt overwhelmed by so much information about diabetes that they wanted to know where the role of case management stops and other professions take over.