CMs use lab values to prove success
CMs use lab values to prove success
Program drops Hb A1C in 71% of diabetics
Licking Memorial Health Systems (LMHS) in Newark, OH, had strong evidence that its community case management program consistently reduced emergency department visits by 40% and admission days by 60% in the roughly 700 patients this active case management service manages each month.
In addition, patient satisfaction surveys consistently showed patients in case management were more than 95% satisfied with the case management service. However, case managers wanted even stronger evidence that their interventions made a positive impact on the health of their patients and the financial health of their organization.
"We thought it was time to focus on other outcome measures that would more clearly identify the impact of case management interventions," says Debbie Young, RN, MS, director of case management and home care at LMHS. "One of the case management initiatives we’ve focused on is our community diabetes management program. We decided to measure the effectiveness of case management interventions with diabetic patients by looking at what happens to hemoglobin A1C [Hb A1C] values after patients receive our services."
Some gratifying news
In December last year, the case management department was providing case management services to 290 diabetics. Of those 290 patients, case managers had collected Hb A1C values on 134. "For those patients, we had an initial Hb A1C value when the patient was admitted to case management and another value within six months of providing service."
Case managers discovered some exciting and gratifying news when they compared Hb A1C values before and after case management. "Of those 134 diabetics, 71% experienced a decrease in their Hb A1C after receiving case management services," Young notes.
Other findings include the following:
• an overall average 9.5% decrease in Hb A1C from time of admission to retesting at six months, or an average 1.05-point reduction in Hb A1C values;
• a 23% to 35% decrease in patients with initial Hb A1C values of more than 10%, or a three- to five-point reduction in Hb A1C values.
"We know from the literature that a one-point reduction in Hb A1C is associated with reductions of 25% in diabetes-related deaths and a more than 50% reduction in cardiovascular incidents. This gives us a strong argument for the effectiveness of our department in improving health and reducing costs for diabetic patients," says Young. "It also made us more determined than before to assure all diabetics regularly obtained Hb A1C values."
LMHS’ case management staff, which includes a director, 13 RNs, an LPN, two social workers, two dietitians, a pharmacist, a respiratory therapist, and a fitness coordinator, sat down to develop a more structured plan for managing diabetes in the community. Certified diabetic educators also work with the community case management team. The staff developed an educational packet and several other tools as part of its ongoing process improvement effort. In addition, the staff worked with the health systems disease management team to develop a physician guideline for diabetes care.
LMHS implemented the community diabetes case management program in 1993 when it became clear that diabetic patients were admitted repeatedly to the emergency department or the hospital for preventable complications of the disease. "The program has become progressively more sophisticated since that time. The case managers have developed great working relationships with the physicians they work with and the physicians have come to rely on the case managers to trigger issues such as routine Hb A1C," says Young.
"We took good care of diabetic patients before the community case management program, but I must admit there were about 20% of patients we couldn’t effect change in," says John W. Walther Jr., MD, staff physician at LMH Professional Family Medical Center. "I would have had to spend a disproportionate amount of time with these patients to get them to be compliant, and that’s something the case managers do much more effectively. The relationships they develop with the patients — the education and support they give — have been very helpful in improving diabetic control."
The referral maze
Patients are referred to case management through a variety of channels. "We all work together on referrals. We receive some referrals from the hospital social workers or inpatient case managers, and some from our physicians," says Teresa Knicely, RN, community case manager at LMHS. "The first step is going out to the home to for an assessment."
She recalls doing a home assessment for one male patient at his physician’s request and finding, as is the often the case, multiple reasons for his noncompliance. "His doctor felt he wasn’t taking his meds correctly and asked me to go check on him," says Knicely. "I found out he was not only illiterate but living in what was no more than a shack. I made a referral to social work; we linked him with a mental retardation agency in town, found him housing, got him taking his meds correctly, and got him a glucose monitoring kit and taught him how to use it," she says.
"I see my patients once a week in the first one to two months, then decrease to monthly in-home or telephone follow-ups. Most patients I check in on at least once every two weeks to make sure they are on track," says Knicely. "Most patients remain in case management for about six months to a year, but that one diabetic patient I described has been in case management for more than four years."
Community case managers have an average active caseload of about 60 patients, including their diabetic population as well as congestive heart failure, asthma, and cancer patients. "Diabetes remains our largest population of clients," says Young. "In the past four years, case managers have been instrumental as part of teams that developed more than 13 outpatient physician guidelines for the treatment of specific disease populations."
Some CM tools
In addition to its physician treatment guidelines for diabetes, the case management service at LMHS developed four tools the staff credit with helping case managers achieve those impressive reductions in Hb A1C values:
1. Extended care: Case management care plan. Diabetics referred to community case management typically are patients who are poorly controlled, noncompliant, and who have several comorbidities, notes Young, adding that it is common for case managers to receive referrals for patients with Hb A1C values ranging from 10% to 17%.
The care plan gives case managers a checklist to follow to make sure they aren’t forgetting important teaching, counseling, treatment, or monitoring issues. The first step in the initial case management assessment is to identify any barriers to compliance, say Young and Knicely.
"It’s common for finances to be a barrier to treatment. Many of our patients can’t afford their medications," Young explains. "The case managers work with the physicians to obtain medication samples for their patients, filling out forms for Medicaid for those who qualify, and working with the pharmacist to find cost-effective treatment options. There are also many programs case managers can refer patients to that offer free or discounted supplies or equipment to help manage diabetes."
The team pharmacist reviews the medications of every diabetic in case management. "Often the pharmacist can make a recommendation for a similar drug to the one prescribed by the physician that would be less expensive," says Young.
Another common barrier to good diabetes management is illiteracy, Knicely says. "Our teaching packet is written on a sixth-grade level with picture guides and videos for those patients who cannot read at all," she says. "For one of my patients, we put a picture of a sun on his morning medication label, a picture of a man eating on his lunch time medication label, and a picture of a moon on his evening medication label." (The extended care plan is inserted in this issue.)
The care plan also helps case managers set realistic treatment goals for each patient, Young and Knicely say. "If you’re not realistic, you won’t gain any compliance at all," says Young. "Many diabetics we work with think because they are taking their medications they don’t have to worry about their diet."
Take easy steps
Young had one patient whose blood sugar was extremely elevated. During an initial assessment, she found out he was drinking 12 cans of regular soda a day. "I asked him to try switching to diet soda. His blood sugar dropped dramatically within a week," she says. "The next step was to ask him to switch some of his diet soda for water. It’s step by little step. You can easily overwhelm patients if you ask for too much at once."
To help them monitor their patients’ progress, case managers provide glucometers for diabetics that store up to 100 readings. Those readings can be downloaded with the help of a computer software program and charted as a teaching tool. "We can produce charts and pie charts to show patients how their blood sugar goes up and down depending on their diet, exercise, and edication compliance," says Young.
2. Diabetic self-management quiz. The self-management quiz is part of the diabetes teaching packet. It gives the case manager a clear picture of patients’ current understanding of their disease and their treatment plan and also makes an excellent teaching tool.
"Patients take the quiz during the initial assessment. If the patient can’t read, the case manager reads the quiz out loud. It gives us a baseline to start the teaching process," says Young. "Case managers start teaching with emphasis on the areas where the patient is least knowledgeable." (For a copy of the self-management quiz, see p. 84.)
Patients take the quiz again at six months. "It’s just a way of making sure nothing got lost in the shuffle and that the patient is now confident and ready for self-management,’ says Young. "The case manager can also pull out the first quiz and compare scores. It’s nice to be able to show the patient how far they’ve come."
3. Diabetes teaching record. The teaching record assists case managers in systematically making sure and documenting that "all the bases are covered," says Young. "The case manager can glance at the teaching record and quickly see which skills the patient has mastered and which skills need to be retaught. Many patients have a low learning level, and case managers must patiently review the same materials on more than one visit. This is even harder if the patient cannot read and all teaching must be done verbally," she notes.
When patients are confident they have mastered a teaching module, the case manager asks them to initial the teaching form next to the appropriate item and then records the date. "It’s an efficient way of documenting that the patient understands the material in the teaching packet," says Young.
4. Physician guidelines. The physician guidelines provide a convenient reminder of the recommended schedule for routine examinations, assessments, and laboratory tests. However, LMHS physicians have come to rely on the community case managers to remind them when routine screening is due and also to keep them updated on their patients’ progress.
"I can track when my patients are due for their Hb A1C with our computer system," says Knicely. "It notifies me when a patient is due, and then I notify the physician."
"The case manager who works with us used to be a nurse in this office," explains Walther. "She [Knicely] comes by once a day to give me progress reports from her most recent case management visit with our patients. If she feels a patient is having a hard time, she makes sure we know it right away.
"I don’t know how we got along without the community case management service, and I would never want to go back to the ways things were before."
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