Case management: a controlled evaluation of persons with diabetes

Integrating Undergraduate Patient Partners into Diabetes self-management education: Evaluating a free clinic pilot program for the Underserved

BACKGROUND

Diabetes self-management education (DSME) improves glycemic control and health outcomes in patients with diabetes.

OBJECTIVE

A process evaluation of a two-year pilot intervention examined the feasibility and acceptability of undergraduate volunteers as Patient Partners to foster DSME participation among the underserved.Design setting, and participants. In the setting of a student-run free clinic, 22 patients enrolled in DSME were paired with 16 undergraduate volunteers. During the DSME courses, Patient Partners assisted patients during classes, called patients weekly, and accompanied patients to clinic appointments.Key process evaluation results. Average attendance at DSME classes was 79.4% and 94.7% for patients and Patient Partners, respectively. Sixty-three percent of phone calls were successful and Patient Partners attended 50% of appointments with their patients. Focus groups demonstrated resounding acceptability of the Patient Partner role.

CONCLUSIONS

Volunteer undergraduate Patient Partners are a beneficial adjunct to DSME delivery in the resource-constrained environment of a student-run free clinic.

Nurse-led case management for ambulatory complex patients in general health care: a systematic review

OBJECTIVE

The aim of this study was to summarize the available literature on the effectiveness of ambulatory nurse-led case management for complex patients in general health care.

METHOD

We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and Cinahl. We included randomized controlled trials, controlled clinical trials, controlled before/after study, and time series studies; identified references were screened by two reviewers. Two reviewers rated the quality of each article. Data extracted from the selected publications included design, characteristics of the participants, the intervention, type of outcome measures, and results.

RESULTS

We identified 10 relevant publications. Nine studies used readmission rate as primary outcome. Fewer studies investigated duration of hospital readmissions, emergency department (ED) visits, functional status, quality of life, or patient satisfaction. In general, results with regard to the effectiveness of case management were conflicting.

CONCLUSION

There is moderate evidence that case management has a positive effect on patient satisfaction and no effect on ED visits. It was not possible to draw firm conclusions on the other outcomes.

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

Case management has been widely promoted as a method that can improve clinical outcomes and reduce healthcare costs. This article describes a cost-benefit analysis for a proposed nursing case management program that provides care for a low-income high-risk diabetic population in a rural county. Industry trends, objectives and functions of the case management program, timeline, financial plan, and cost analysis are described. The analysis indicated a potential net savings of 149,544 dollars annually. This would be a significant cost savings for the healthcare provider and funding source.

Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study

OBJECTIVE

Disparities exist in the diabetes health status of ethnic minority and/or low-income populations relative to other groups. A primary objective of diabetes management is to improve glycemic control. The feasibility of implementing intensive diabetes case management in disparate populations remains largely untested.

RESEARCH DESIGN AND METHODS

Clinical sites in three southern California counties serving low-income, ethnic minority populations participated in our study. We randomized 362 Medicaid (called Medi-Cal in California) recipients with type 2 diabetes for at least 1 year to intervention (diabetes case management) or control (traditional primary care treatment) groups. Fifty-five percent of participants were minorities. Participants with HbA(1c) levels less than 7.5%, serious diabetes-related complications, or other serious medical conditions were excluded. We assessed the effect of the intervention (ongoing diabetes case management added to primary care) on glycemic control using serial HbA(1c) measurements over several years.

RESULTS

The mean duration of follow-up was 25.3 months. HbA(1c) decreased substantially in both groups from an average of 9.54-7.66% (a reduction of 1.88%) in the intervention group and from an average of 9.66-8.53% (a reduction of 1.13%) in the control group. This improvement was sustained throughout the study. The reduction in HbA(1c) was consistently greater in the intervention group at each time point (P < 0.001), ranging between 0.65 at 6 months and 0.87 at study end.

CONCLUSIONS

Diabetes case management, added to primary care, substantially improved glycemic control compared with the control group. Diabetes case management can help reduce disparities in diabetes health status among low-income ethnic populations.

Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria

OBJECTIVE

Little is known about the impact of disease management programs on medical costs for patients with diabetes. This study compared health care costs for patients who fulfilled health employer data and information set (HEDIS) criteria for diabetes and were in a health maintenance organization (HMO)-sponsored disease management program with costs for those not in disease management.

RESEARCH DESIGN AND METHODS

We retrospectively examined paid health care claims and other measures of health care use over 2 years among 6,799 continuously enrolled Geisinger Health Plan patients who fulfilled HEDIS criteria for diabetes. Two groups were compared: those who were enrolled in an opt-in disease management program and those who were not enrolled. We also compared HEDIS data on HbA(1c) testing, percent not in control, lipid testing, diabetic eye screening, and kidney disease screening. All HEDIS measures were based on a hybrid method of claims and chart audits, except for percent not in control, which was based on chart audits only.

RESULTS

Of 6,799 patients fulfilling HEDIS criteria for the diagnosis of diabetes, 3,118 (45.9%) patients were enrolled in a disease management program (program), and 3,681 (54.1%) were not enrolled (nonprogram). Both groups had similar male-to-female ratios, and the program patients were 1.4 years younger than the nonprogram patients. Per member per month paid claims averaged 394.62 dollars for program patients compared with 502.48 dollars for nonprogram patients (P < 0.05). This difference was accompanied by lower inpatient health care use in program patients (mean of 0.12 admissions per patient per year and 0.56 inpatient days per patient per year) than in nonprogram patients (0.16 and 0.98, P < 0.05 for both measures). Program patients experienced fewer emergency room visits (0.49 per member per year) than nonprogram patients (0.56) but had a higher number of primary care visits (8.36 vs. 7.78, P < 0.05 for both measures). Except for emergency room visits, these differences remained statistically significant after controlling for age, sex, HMO enrollment duration, presence of a pharmacy benefit, and insurance type. Program patients also achieved higher HEDIS scores for HbA(1c) testing as well as for lipid, eye, and kidney screenings (96.6, 91.1, 79.1, and 68.5% among program patients versus 83.8, 77.6, 64.9, and 39.3% among nonprogram patients, P < 0.05 for all measures). Among 1,074 patients with HbA(1c) levels measured in a HEDIS chart audit, 35 of 526 (6.7%) program patients had a level >9.5%, as compared with 79 of 548 (14.4%) nonprogram patients.

CONCLUSIONS

In this HMO, an opt-in disease management program appeared to be associated with a significant reduction in health care costs and other measures of health care use. There was also a simultaneous improvement in HEDIS measures of quality care. These data suggest that disease management may result in savings for sponsored managed care organizations and that improvements in HEDIS measures are not necessarily associated with increased medical costs.