Diabetes management pays off for HMO
Hospitalizations decrease 50%; ER visits 40%
A program to help members with diabetes manage their disease has paid off for ConnectiCare, a small regional HMO based in Farmington, CT.
Members in the DiabetiCare program for adults with diabetes had a 53% decrease in hospitalizations and a 44% decrease in emergency room visits for 12 months after they received case management from a DiabetiCare nurse case manager compared to 12 months before their first contact, reports Steve Delaronde, MPH, MSW, an epidemiologist and research analyst with ConnectiCare’s Health Management Programs.
The DiabetiCare program was started in 1998 because of the prevalence of the disease among ConnectiCare’s population.
"We had about 8,000 members with diabetes. It was a prevalent diagnosis in our membership as well as being a high-utilization and high-cost diagnosis," says Jay Salvio, BSN, MBA, director of ConnectiCare’s Health Management department.
A multidisciplinary team including physicians, medical directors, and case managers put the program together.
The program started in 1998 with one case manager, Ginette Levesque, RN. Gina Dulak, RN, joined ConnectiCare as the second DiabetiCare case manager in January 2001.
There are about 10,000 members in the program, most of whom were identified by a computer algorithm developed by ConnectiCare. The rest come from self-referrals or referrals from case managers, physicians, or diabetes educators.
Regular computer scans of claims data identify members who have at least two medical claims for diabetes or have filled a prescription for a diabetes-related drug.
The majority of the members with diabetes are managed on a population-base level. They receive educational material on subjects such as how to test blood sugar, how to manage diabetes, and the importance of getting regular eye examinations.
When they get the names of members with a diagnosis of diabetes, the case managers assess them to determine if they need case management or if mailed educational materials will suffice.
"We try to get the new ones into the program before their disease gets to the point that they need a lot of care," Levesque says.
ConnectiCare uses the laboratory test results of members who have A1C or cholesterol tests to identify those who are at the greatest risk of developing complications according guidelines established by the American Diabetes Association (ADA), Delaronde says.
Those with an A1C level of 7% or higher or an LDL cholesterol level that exceeds 100 mg/dl are identified as the highest-risk members.
The case manager begins making the telephone assessments for those with the highest A1C results.
During the first telephone call, the case managers assess the members and their knowledge of diabetes and their willingness to change their lifestyle in order to get their disease under control.
Other topics for discussion include their individual treatment plan, ADA goals and guidelines, and the importance of good nutrition.
The case managers break out different parts of the program for follow-up telephone calls because they know that the members can’t absorb everything they need to know at once.
"All of them have different needs. Some know a little. Others are very knowledgeable; they just aren’t doing what they should. We do a lot of encouraging and a lot of empowering the member," Dulak says.
The case managers initially call the members who are at high risk every two weeks.
"They’re good at receiving the first couple of telephone calls and responding. After that, it’s more difficult to get in touch with them," Levesque says.
The case managers review the blood sugar level with the members and follow them until they get into the normal range.
"I can usually get a feel for whether or not they will continue monitoring their blood sugar level. It takes four to five telephone calls before we can come to any conclusion," Dulak says.
Because diabetes can lead to depression, the diabetes assessment includes a depression-screening program. If it appears a patient is depressed, the DiabetiCare case managers refer them to the mental health case managers.
"You can’t change your lifestyle if you’re depressed. We have to get the depression taken care of first," Levesque says.
The case management program serves both the members with diabetes and the practitioners who treat them, Salvio points out.
ConnectiCare provides practitioners with updated American Diabetes Guidelines for the management of diabetes and sends them a report every six months listing all their patients who have not had an A1C examination or a cholesterol test and those whose levels are so high they should be addressed by the physician.
"We have been successful in empowering the patients to speak with their physicians about their treatment plans. We give them the knowledge they need to ask the right kinds of questions of their doctor," Levesque says.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.