Executive Summary
A case management program for a large health system has produced dramatically improved healthcare and cost savings results, including the following:
- Case managers meet monthly in person with patients to assess and educate them.
- The program provides incentives, such as free medical supplies and medications.
- Case managers refer patients to specialty services, including dietary education, exercise facilities, and counseling.
When the care management program for a large health system’s employee and plan member population began its wellness program in 2009, the impetus was unsustainably high health claims for diabetics and other chronically ill patients.1
“The claims for diabetics were much higher than most other chronic diseases,” says Geronda C. Pulliam, RN, BSN, MS, CCM, assistant clinical director of care management for Triad HealthCare Network in Greensboro, NC. Triad HealthCare Network is the largest accountable care organization (ACO) in North Carolina, spanning a four-county area.
“On average, the health system’s insurance plan was paying $5,885 per year for each member with diabetes in 2009,” Pulliam says. “We found that part of the issue was that people were not very good at self-managing their diabetes, as far as not regularly checking their blood sugar levels, not visiting their doctor, and not making lifestyle changes.”
Patients encountered barriers that included transportation, financial issues, and a lack of education.
“We had many emergency room visits, hospitalizations, and we had a lot of patients who were having amputations,” Pulliam adds.
For these reasons, they decided to change their approach to care for patients with diabetes, other chronic illnesses, and pregnancies.
The resulting program, called Link to Wellness, involved having case managers meet with patients and work to remove barriers to better health. The program has grown to more than 500 patients and three case managers who work with them, Pulliam says.
Plan members often self-refer to the program once they hear about how its benefits include free diabetes testing supplies, including a glucometer, Pulliam says.
“That is one of the barriers we had heard in the process of enrolling people in the program,” she says. “A monthly supply of diabetes testing strips usually costs $50 or more.”
Most members of the program will say they joined to receive the free supplies, says Janet Hauser, RN, CCM, CDE, RN, care management coordinator for Triad HealthCare Network Care Management in Greensboro.
“That’s the carrot we dangle,” she adds. “Once we get them in here and establish a relationship with them, then it’s all about educating them about their disease and how to self-manage.”
In addition to free supplies, diabetic patients receive education and disease management from a certified diabetes educator and RN case managers. They also receive some medications at zero or reduced co-pays, free classes, and one-on-one counseling. Patients with hypertension receive blood pressure monitors for $5, as well as free disease management services.1
The cost of providing the free supplies and medications, as well as funding the case management, has proven to have a great return on investment, Pulliam says.
“It’s paid for itself,” she says.
“We have this wonderful network of people we can refer patients to, including registered dieticians, personal trainers, and anyone who will help that member get a better handle on what’s going on with them, including offering free exercise classes,” Hauser says.
The health system’s employees have access to 24-hour exercise rooms at each campus, she says.
“We are the overall case management program for the employees,” Pulliam says. “Other than diabetes, hypertension, and hyperlipidemia, we also follow members with congestive heart failure, chronic obstructive pulmonary disease, and other medical issues.”
Results include the following:
- diabetes care costs dropped from $5,885 in 2009 to $543 in 2014,
- healthy pregnancy trends include preterm labors declining from 7.6% in fiscal year 2011 to 6.2% in FY13,
- average A1C decreased from 8.00 to 7.28,
- average triglycerides decreased from 160 to 131,
- members exercising increased from 50% to 76%,
- admit days per 1,000 members decreased by 24.3%,
- hypertension costs declined from $5,145 in 2009 to $241 in 2013, and
- hospital admissions for all members enrolled in the new plan decreased by 9.7% between 2012 and 2013.1
“We have a 98% satisfaction rate in our Link to Wellness program,” Pulliam says.
Anyone who is on the health plan is eligible for the program, although the bulk of the program’s work is for people who are diabetic, Hauser says.
“We don’t turn down anyone who needs assistance if they are having trouble managing a health issue,” Hauser adds.
When the program began six years ago, the insurance provider sent out letters and marketed the program within the healthcare system, Pulliam says.
“The insurance plan would say, ‘Do you have diabetes or a history of diabetes in your family? Give us a call,’” she says. “Then those who called, we did an intake, and we also incentivized the program.”
The program also receives referrals through health fair screenings, physician offices, and pharmacies.
“One of our biggest referral sources is the pharmacy,” Hauser says. “If we have members filling medications at the pharmacy for diabetes, the pharmacy techs will say, ‘You could be getting your strips and meds at no cost if you enrolled in Link to Wellness.’”
Evidence-based research showed that people enrolled in a wellness program would have better success rates — both short-term and long-term outcomes — when they received healthcare incentives, such as free medication and medical supplies, she explains.
To continue to receive their medication or supplies, patients have to keep monthly appointments with their case manager and visit their physician as directed. “We have a dedicated office where members come to visit,” Pulliam says.
People enrolled in the program also attend education classes.
When Hauser asks the people she sees how they heard about the program, they often answer that it was through a blood pressure check or blood sugar screening at one of the program’s quarterly health screenings or regular benefit fairs.
“We give them a little sheet, saying, ‘Your blood pressure is high, and you need to go to a doctor, or — if it’s very high — go to an ER,’” Hauser says.
For example, Hauser recently met with a middle-aged man who is a Liberian refugee. He has hypertension and learned about the program after a blood pressure screening. The man had not seen a doctor in more than 11 years when he was hospitalized for hypertension.
“I talked with the man about self-management, which is what we do,” Hauser says. “I told him that I’d like to show him how to monitor his blood pressure at home, so when he goes into a doctor’s office he can show the physician his readings.”
Hauser demonstrated the way to use the blood pressure machine, which the man received for free from the program, and document its readings. She explained what normal readings are.
REFERENCE
- Hauser J, Sandlin M, Pulliam G, et al. Successful patient engagement in an employer-based wellness program. Poster presented by Triad HealthCare Network at the Case Management Society of America’s 25th Annual Conference & Expo, held June 23-26, 2015, in Orlando, FL.