Health plan moves diabetes management in-house.

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.