Health plan moves diabetes management in-house
Care managers work with members at highest risk
After four years of positive experiences with a
national disease management vendor, Fallon Community Health Plan in
Worcester, MA, decided it would be more beneficial to members and providers
if the diabetes management program was transitioned in-house.
The health plan chose an outside vendor when it
started its diabetes management program in order to get the program under
way quickly, says Wally Mlynaryk, MHA, director of disease management for the health plan.
?They definitely did have a positive impact on
our program, not only in terms of decreasing resource consumption by
members but also in improving the clinical parameters as gauged by
HEDIS [Health Plan Employer Data and Information Set] figures,? he
says.
Fallon Community Health Plan decided to bring the
program in-house to give the program a local focus. Care managers are
assigned to specific clinic sites throughout the health plan?s
service area so that the related physician group has a single point of
contact for its enrolled members.
Under the vendor?s program, physicians might
receive phone calls from several different care managers, Mlynaryk says.
?It gives the providers an opportunity to talk
to one person about all of their patients. They have one person to call if
they have questions about the program or want help in maximizing the
benefits of the program,? he says.
Fallon Community Health Plan?s diabetes
management program includes care for both high-risk and low-risk members
with diabetes.
Among the 13,000 diabetics covered by Fallon Community
Health Plan, about 3,000 have been assigned to the high-risk subset.
High-risk members typically are not managing their condition and are
regularly telephoned by a care manager who monitors, educates, and supports
the patient.
The health plan mines its claims data for members who have the
potential to have complications of diabetes in the future. Risk factors the
plan considers include hemoglobin A.sub.1C levels, creatinine levels, and past utilization
history.
?These are strong predictors of future
utilization for the diabetic population,? Mlynaryk says.
The health plan monitors lab values of members
monthly. If a member?s A.sub.1C levels and creatinine levels are stable, he or she may
be moved to a lower category or moved into the high-risk management
program.
Members who are not in the high-risk population
receive a quarterly educational newsletter created by the care management
staff.
The diabetes team at Fallon Community Health Plan is working to develop a group
follow-up program that would allow members to meet other members enrolled
with the program as well as have a face-to-face meeting with their care
manager.
It took the staff at Fallon Community Health Plan
about a year of planning to make the switch from using a vendor to handling
disease management in-house.
The plan already had established an Internet data
registry for its other disease management programs and was able to include
diabetes data in the registry fairly quickly, Mlynaryk says.
?We were able to take the same snapshot of the
platform and modify it for diabetes,? Mlynaryk says.
The vendor had established a high-risk group, some of
whom did not meet the criteria set by Fallon Community Health Plan for its
high-risk group.
When the program started, those members received
letters notifying them of the changes in the program and telling them that
even if they did not meet the new high-risk criteria, they still would be
monitored.
The health plan visited providers and told them the
rationale for moving the program in-house and the benefits the new program
would provide. Physicians also received a letter describing the new
program.
When a member is referred to the high-risk program,
whether by the health plan?s stratification process or a direct
referral, the plan gets the approval of the primary care provider before
starting the disease management program and gives the member an opportunity
to opt out.
A few members have refused to participate, Mlynaryk
adds.
?Since we?re look at a high-risk group, we
use a combination of education and training. The real thrust is to try to
get the members to check their blood sugars at home,? says Janice Betz, RN, senior clinical
manager at Diabetes Care.
The care managers have rough guidelines for frequency
of calls and often take their cues from the members as to how often to
call, she says.
Members could get a call as frequently as weekly or as
infrequently as quarterly.
?Some have a lot going on and don?t want
to be called every week. We will negotiate on how often we call,?
Betz adds.
The care manager takes into consideration how long the
member has had diabetes and assesses his or her knowledge of the disease to
decide if the member needs a full-blown educational program.
If so, he or she is referred to the diabetic education
programs, a diabetes nutrition program, or both.
The diabetes program?s nurse care managers also
address comorbidities, such as asthma or congestive heart failure, Betz
says.
