|Title:||United States pilot and non-pilot programs for diabetes case management by program type with patient participation and improvement in percentages for 2007 and 2009|
Start of full article - but without data
Patients XX-XX yrs old
2007 2009 Improvement
Pilot LDL-C once/year XX% XX% XX.X%
Non-Pilot XX% XX% X-X%
Pilot HgbAXC twice/year XX% XX% XX%
Non-Pilot XX% XX% X.X%
Pilot Nephropathy Once/Year XX% XX% XX.X%
Non-Pilot XX% XX% X.X%
2009 year-end report
As a nation, we have fragmented care, inconsistent quality and variation of care, and models of primary care services that are not patient-centric. We have processes of care that are based around the needs of physicians and clinics rather than patients.
The processes involved in the delivery of care need to be re-engineered so that they can drive quality, cost-efficiency and consistency, as well as provide a satisfying patient experience and improved quality of life for our patients.
In addition, we have a disconnect between wanting to reduce hospitalizations, emergency department visits and unneeded procedures and tests, yet are still dependent on a fee-for-service model of reimbursement where we are paid for doing more rather than doing what is evidence-based or cost-effective.
These are well-known facts: the United States spends over $X.X trillion a year on health care (XX percent on chronic disease) with these costs increasing faster than inflation; only XX percent of recommended care is received by our patients (RAND); we are certainly not getting value for our health care dollars when you consider the United States spends the most on health care compared to any other nation, yet we rank XXth in quality (by the World Health Organization, 2008).
Chronic disease management is critical for patients like this whom we all know or have known:
Mrs. Unengaged, a XX-year- old diabetic patient who is currently not engaged in her health care and has not been seen in the last nine months. Her last HgBAXC was XX. She's not had an eye exam for five years and has not had any health maintenance done. She's not sure why she needs to take her medication even when she feels good. And she does not fill her prescriptions on a regular basis.
Suddenly, she presents to her primary care provider's office to be seen because she is getting out of breath when walking up stairs. We all have a "Mrs. Unengaged" in our practices or in our families. We need to do a better job of engaging her and making sure she receives the care she needs to improve her quality of life.
In order to do that we need not only engaged patients but also engaged providers. Mrs. Unengaged was a significant motivation for creating a diabetes chronic disease management program (CDMP) at MultiCare Medical Associates, a $X.X billion, four-hospital health system based in Tacoma, Washington.
MultiCare understood that we could do much better at providing chronic care services to our patients and the community we serve. Why weren't we able to engage Mrs. Unengaged? What are her barriers to getting healthy and having an improved quality of life? Was it time for us to stop focusing on compliance and instead work diligently to engage Mrs. Unengaged and her primary care provider?
We had not been as effective as we could in providing recommended diabetic care or improving quality of life or clinical outcomes for our diabetic patients. We envisioned a chronic disease management program with:
X. Patients actively engaged in their care.
X. Providers engaged with their patients.
X. Change and improved processes that are embraced and welcomed.
X. Decreased costs of chronic disease management, for both patient and provider.
X. Everyone seeing the value of the program and wanting to participate.
X. Providers and staff buying in to the concept of chronic disease management.
X. Resources and monies available to support the program.
X. Immediate results.
X. Patients and providers highly satisfied with the program.
But the reality is:
* Few of us like change, including patients, administrative folks and providers.
* Everyone has a vision and these multiple visions rarely match reality.
* It takes time to see even incremental improvement.
* There are limited resources and dollars available to fund such programs.
* It is difficult for people to see efficiencies that will result after the process changes are implements in systems of care.
* The chronic disease management program had to be revised due to resource restraints and changed to include centralized as well as a local in-clinic component.
* It is a complex undertaking and requires perseverance and good change management skills.
* You can never communicate enough.
* And finally, again, no one likes change!
We established a chronic disease management oversight committee to advise and approve program components. It comprised interested and influential providers and managers. The program's operations team worked closely with the oversight committee that endorsed the processes and goals of the program. We chose diabetes for several reasons:
X. A significant population of over XX,XXX patients, growing at XX percent per year (our diabetic population increased from 2007 to 2008 by XX percent and from 2008 to year-end 2009 a further X percent increase for a total of XX,XXX). In 2010 we had almost XX,XXX diabetic patients.
X. Evidence-based guidelines for care exist.
X. Quality measures were well-established and could be tracked.
The chronic disease management program began in three primary care clinic pilot sites but was soon expanded to our remaining XX primary care clinics when the oversight committee felt that it had value (after about six months) and should be expanded.
Our program was population-based management and included leveraging our electronic health record in generating lists of diabetics (or registries) that were actionable. We needed to engage patients who were unengaged and keep those patients who were engaged in their diabetes care focused on their health.
X. Diabetics who had not been seen in more than one year, but had previously been seen within our clinic settings, were contacted. This involved calling the patient and reengaging them into their care and getting them back in to be seen with needed labs completed prior to the office encounter. This allowed for a much more efficient office visit and any changes in treatment could be done at that time rather than having a return visit or a telephone conversation. This saved costs for the patient and it also freed up an appointment for a new patient visit. If telephone contact was not successful, repeated attempts were made at contact and if this still was not successful we sent out letters to this group of patients.
X. Next, diabetic patients who needed prescribed follow-up appointments, at three, four or six months, and who were already being regularly seen in our clinics were contacted to ensure they understood the importance of their appointment and that their provider recommended they maintain their appointment. The program staff also made arrangements for the patient to have their diabetic labs (and other ordered labs) completed several days prior to their visit. There was flexibility in scheduling to allow for patient and provider choice.