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••Fall 1998 / Vol 2, No 4 |
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Health Systems The Care Management Institute's Integrated Diabetes
Care Program: Introduction You're running late today and scheduled a lunchtime meeting with your Chief of Service. As you thumb through Ms. Hopeful's thick medical chart for evidence of her last eye examination and relevant screening studies, you ask her about her diet and self-monitoring of blood glucose level. She tells you she thinks she is "doing okay" with her diet but could probably do better. She says she checks her finger stick results a couple of times a month and that they usually run 200 to 300 mg/dL, sometimes higher. She has not smoked in five years, she is proud to tell you. By the end of her review, you still have not located records for her last eye examination-–and the patient cannot recall when she last had one. Neither can you find the laboratory data for her last check of HbA1c, microalbumin, lipid, or TSH level. You are also falling farther behind in your schedule, and you know that your Chief is a stickler for punctuality. The Integrated Diabetes Care (IDC) Program was created for people like
Ms. Hopeful. In an integrated Ms. Hopeful's microalbumin level turned out to be elevated when last checked. This result--confirmed by repeat testing--is early evidence of end-stage organ damage. Ms. Hopeful is an excellent candidate for care management. Care management allows a more coordinated approach to care by using a multidisciplinary team. A care coordinator ensures that all appropriate laboratory values are checked, that the patient is given lisinopril as treatment for nephropathy, that the patient's blood glucose level is controlled through both improved diet and medication management, and that the patient is taught the importance of self-care. After completing a care management program, Ms. Hopeful says she feels more confident of her ability to participate in her own care and now understands why she must not miss any appointments. She returns to your care with all screening in order and with her medications fine-tuned. You know you will receive regular updates on her screening tests through the quarterly diabetes reports for your patient panel. The Need for Coordinated Diabetes Care The consequences of diabetes are profound. Diabetes is responsible for increased rates of myocardial infarction, stroke, kidney disease, and limb amputation, among other serious ailments. Consequently, caring for the complications of diabetes leads to dramatically higher health care costs. A national study found that the cost of caring for the typical health plan member with diabetes was more than four times the cost of caring for nondiabetic members.2 Within KP, the cost differential was best measured in a Division of Research study led by Joseph Selby, MD, MPH, that compared cost of caring for KP Northern California diabetic patients with the cost of caring for a matched cohort of nondiabetic patients. The study found that the cost of caring for diabetic patients was approximately twice the cost for nondiabetic patients, suggesting that better care may provide an opportunity for savings, ie, by reducing the $20 million differential in cost of diabetes care in the KP Northern California Region.3 Studies have shown that careful diabetes population management is highly cost-effective.4,5,6 CMI's Integrated Diabetes Care (IDC) Program With the goal of systematically evaluating and improving care of our
adult members with diabetes, CMI released an Integrated Diabetes Care
(IDC) Program in January 1998. Work is now underway in almost all KP
Regions to implement a care management program for all members with
diabetes. (Some KP Regions already have such a program in place and
provided much of the expertise for the CMI IDC Program's development.)
CMI's IDC Program grew out of KP's Interregional Diabetes Effort, a
national Combining the knowledge and experience of many KP physicians and health care professionals across the nation, the IDC Program provides tools for national, Programwide implementation of KP's Clinical Practice Guideline for Adult Diabetes Care as well as evaluation of this implementation against a set of outcomes measures. The IDC Program also includes a curriculum for patient education and care redesign. The core components of the IDC Program include Clinical Practice Guidelines for Adult Diabetes Care; use of tools that emphasize patient education and empowerment; and attention to monitoring and tracking outcomes for the population of diabetic patients. As part of the IDC Program, CMI has produced two implementation manuals: The Integrated Diabetes Care IDC, Version 1.0 manual is intended to assist local KP areas in design, implementation, or enhancement of programs for adult diabetic patients; Living Well With Diabetes, Step by Step manual is an interactive patient education curriculum that promotes self-management and skill-building for people living with diabetes. The IDC Program focuses on approaches that are either distinctive or emphasized in the current medical literature. Tools used as part of the IDC Program are designed to be as generalizable as possible, providing flexibility so that physicians and other health care professionals can adapt them to their own patients and unique care settings. Some tools may need to be customized for special patient populations. Although the IDC components and tools can be implemented separately, care management programs are most effective when they are fully integrated to provide a comprehensive approach to caring for the target population; implementing individual pieces alone appears to have far less impact. However, no formal outcomes data are available to compare the efficacy of implementing a whole program versus the efficacy of implementing only some component parts. Process for Developing the IDC Program Clinical Practice Guidelines of the IDC Program Presented (Figs. 1-3) are excerpts from the IDC Clinical Practice Guidelines for Adult Diabetes Care in three areas--glycemic control, renal screening, and podiatric screenings--which are especially important in diabetes care. Clinical Practice Guidelines for Adult Diabetes Care can be found on KP Exchange, a secure Internet website for use by clinical and nonclinical employees of KP (who may register online at www.kpexchange.org). Glycemic Control Renal Screening Podiatric Screening Model of Care The model of care has four important components: population identification through a registry; stratification of patients; commitment to a team approach; and evaluation of care. Population Identification Through a Registry
A registry can also be used to generate targeted mailings or clinical feedback reports and for other quality improvement projects. Reports also can be generated to show employers the care which their at-risk employees are receiving from KP. Stratification of Patients At initial patient evaluation or when reviewing the local patient registry, the diabetic patient population must be segmented into groups most likely to benefit from different levels of intervention. The stratification methodology is intended to be coupled with other aspects of the IDC Program (ie, patient education, group visits, and programs for self-management of chronic disease) that provide direct service to patients. The stratification process relies on available KP data bases, allowing segmentation of the entire diabetic patient population without necessitating additional intake interviewing. The stratification methodology in the IDC Program creates three tiers of patients with diabetes. The patients with the least severe disease are well controlled and usually have no evidence of end-stage organ damage. These patients will continue to receive most services in the usual way from their primary care physician or health care professional. Depending on available resources and maturity of the Program, some of these patients may also be targeted to receive additional educational programs to improve their diet and activity levels. Patients with the most severe disease (about 15% of the diabetic patient population at any time*) have major, multiple complications from diabetes, often requiring subspecialty services. Comorbidity caused by long-standing diabetes is often the major medical problem. These patients are potential candidates for "case management." Between these two extremes is a sizable cohort of patients who have clinically significant diabetes care needs but whose care management can be handled well through a care coordination system. Typically, this cohort represents about 50% to 60% of diabetic patients (depending on age and severity of the cohort as well as on the criteria used for inclusion and exclusion). Markers for these patients include
The exact mix of inclusion and exclusion criteria as well as duration of enrollment in a care management program should be determined, using different markers, in consultation with the local KP leadership through iterative review of the size of the three strata. Another criterion for assigning patients to care management is candidates' readiness to make major lifestyle changes. To obtain such information, however, all candidates must be interviewed. Local KP leaders should decide whether to evaluate this parameter. Commitment to a Team Approach The local KP leadership should determine how care can best be complemented through use of nonphysician clinicians who have diabetes-related clinical expertise. In addition, a key contact at the local level must be identified to explain care priorities and to provide patient registry data at timely intervals. Evaluation of Care
Computer software for population management is a key tool for care coordination and is an important component of diabetes care management. Ideally, software should be able to quickly identify patients in trouble--for example, those who are not filling prescriptions or whose blood glucose levels are becoming dangerously high--and to remind care coordinators about scheduled follow-up care. The software should also be able to broadcast messages by e-mail, phone, fax, or paper to other team members (and, in future, to patients). Current approaches can deliver some of these services. The KP National Clinical Information System currently under development is expected to provide these services in the future. In the absence of computer software, other tools can lend assistance for care management. For example, CMI has developed a template for a paper version of "speed charting" for patients with diabetes (Fig. 5). The Speed-Charting Template allows clinicians to easily check and record pertinent clinical data at routine scheduled visits. A Personal Diabetes Record (Fig. 6) is another paper-based way to monitor the health status and treatment history of diabetic patients in the absence of computer software. Patients are encouraged to use the wallet-sized card to record their medical visits and laboratory test results. They take the wallet card with them when they visit their physician or other member of the Diabetes Care Team, using it to discuss aspects of their care. The card unfolds to reveal panels which include space for listing areas for discussion, for noting goals, and for recording medications, medical visits, laboratory test results, and phone numbers. In this way, the wallet card helps members to monitor and control their own health. Patient Education To change the traditional, didactic method of diabetes education, patients are asked to set and pursue specific, attainable goals and to develop individual self-management skills. Educational messages are tailored to each patient's readiness for change and to each provider so that they are continually reinforced. The IDC Program includes several patient education tools to help members take charge of their health. Templates from the Diabetes Action Plan (Fig. 7) enable patients to note their personal behavior change goals, a copy of which can be made part of the medical record for regular review. Tip Sheets (Fig. 8) containing helpful self-care information for members with diabetes also are included as part of a patient education section. The IDC Patient Education Workgroup adopted this tip sheet from the American Diabetes Association (ADA) materials. An important recommendation (not included in the ADA handout) is the need to counsel patients about the use of metformin during sick days. Diabetes Outcomes Report and Patient Survey Especially when embedded in a population management system, outcomes measures can help identify exemplary practices and can point to areas for improvement. The 1997 KP National CMI Adult Diabetes Outcomes Report used administrative data to provide information on processes of care, utilization, and clinical outcomes of interest for more than 200,000 KP members with diabetes. The report represents major work by representatives from across KP to identify patient groups consistently and to measure outcomes equivalently. This reporting process is expected to be repeated regularly and will be valuable for tracking trends over time. After collecting administrative data, CMI surveyed members with diabetes to collect data available only from patients (eg, self-perceived health) or which cannot be reliably measured from other data sources (eg, foot examinations by physicians). The patient data survey summarizes measures of medical care interventions, self-care attitudes and behaviors, satisfaction with medical care, and patient perceptions of health status. CMI collected data from 7123 respondents and summarized its findings in the report, 1997 KP National CMI Survey of Adults with Diabetes, which is available on the KP Exchange website (www.kpexchange.org). Concluding Overview Although content development is important, implementation efforts are
the core of CMI's work. An implementation network across KP is using
the IDC program as it works with clinicians at the local level to assist
them in improving outcomes for members with diabetes.
KP staff can access the Integrated Diabetes Care Program directly on the KP Clinical Practice Exchange website (register at http://www.kpexchange.org). Acknowledgment: The Care Management Institute gratefully acknowledges the contributions of the Northern California Region, the Northwest Region, and the IDC Patient Education Workgroup, whose work served as the basis for the Living Well with Diabetes Step-by-Step materials. * Population proportion estimates developed by diabetes outcomes researchers and program developers and validated against medical center level data in South San Francisco. Return to text References
Commentary: The Care Management Institute's
Integrated Diabetes Care Program In the ongoing wave of discontent about health care in the USA, two themes surface repeatedly in the political rhetoric and oversimplified soundbites from the media. The first is that consumers should have the freedom to go anywhere and choose anyone (specialists, alternative therapies, etc.) whenever they feel they need help. The second is that the phrase "managed care" is increasingly used as a pejorative euphemism for "bad care," with all managed care organizations (MCOs) being lumped together as heartless money-grubbing demons which exist to make money for their shareholders by denying critical services to their hapless enrollees. There is certainly some justification for the concerns being raised, and there is plenty of room for improvement in the US health care system. But for those of us who work for organizations like Kaiser Permanente (KP), who dedicate our efforts to improving the health and quality of life for our enrolled members, this misrepresentation of managed care is hard to take. I would like to see two different themes receive increasing prominence in the near future. The first of these is that the biggest concern for the US health care system ought to be how to deal effectively with the ever-growing problem of chronic disease. And the second is that NOT all MCOs are the same. The article by Rachelle Mirkin, Neil Solomon, MD, and Helen Pettay in this issue of The Permanente Journal is a wonderful example of how organizations like ours can deal with chronic disease in ways that simultaneously will improve health outcomes, patient satisfaction, quality of life, AND reduce overall costs. I believe that this kind of work will set us apart from our competitors and should be promoted and expanded throughout our system. Individuals with a chronic condition like diabetes dominating their lives need much more than cheap, easy access to a variety of services and specialists whenever they think they need help. They need to be empowered to take a central role in a health care team to utilize a coordinated set of services and supports that will promote better health outcomes and improved quality of life for them, long before they feel that they NEED to seek out someone because of a "problem." In other words, they need "well-managed care." The Care Management Institute's Integrated Diabetes Care Program grew out of KP's Interregional Diabetes Effort and has taken the knowledge and experience of many KP health care professionals across the nation. The goal was to develop a nationally consistent, evidence-based, process-efficient, and population-based approach to diabetes care that is customized to the individual member with diabetes. The keys to this approach are to first identify all diabetic patients by using consistent methods so that comparisons among different groups around the country are valid. Second, the key elements of good diabetes care need to be agreed on and defined. All these elements of care can then be tracked for all diabetic members on an ongoing basis (ideally using sophisticated electronic registries). Third, evidence-based guidelines for improving diabetes care need to be developed and become embedded in the health care system to ensure that they are followed. Fourth, patients need to be stratified so that the appropriate level of care and support can be customized to meet each diabetic patient's needs. All patients should have a clear, collaboratively developed Action Plan that is communicated to all team members. Last, the success of this integrated effort needs to be continuously evaluated throughout the KP system and be modified as needed to foster continuous improvement. As described in the article, although not all these elements are being actively employed in all KP Regions of the country, the Care Management Institute has the goal of facilitating rapid dissemination of the relevant skills and resources to where they are needed. And in Regions where most or all of the components have been implemented (such as in KP's Northwest Region, or Group Health Cooperative of Puget Sound), the improvement in patient satisfaction and health outcomes has been clearly shown. Another criticism which is often leveled against this kind of integrated approach to managing care is that it takes away from the individual freedom of both the patient and the provider to do what they think is best. I believe that this is a myth. There is plenty of evidence in the literature that the uncoordinated traditional approach to managing chronic illness like diabetes has resulted in abysmal outcomes, unhappy patients, and inefficient and expensive care. A coordinated and integrated program like the one described here, which gives timely reminders about what services are recommended along with a range of options for supporting good decision-making and behavior change, can actually increase the sense of well-being and freedom for the patient and the other members of the health care team. This work should be applauded and should be expanded to all regions of our organization as well as to other chronic conditions. Not only will it result in healthier, happier enrolled members, it is likely to reduce our overall costs of care, all of which will improve our competitiveness and make it clear to anyone who cares to dip below the superficial surface of rhetoric and soundbites that some MCOs are VERY much better than others.
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