For Staying Power, Diabetes Interventions May Need a Hands-on Element

It was clear to Kate Lorig, DrPH, immediately that she was dealing with a special case in her type 1 (T1DM) and type 2 diabetes mellitus (T2DM) self-management workshop at the Stanford Patient Education Research Center, where she serves as director. Lorig had asked a female diabetic what sort of a commitment she could make to reduce her sugar intake.

The woman replied that she would eat no more than 2 candy bars a day. While that’s not an ideal goal for a diabetic, Lorig didn’t bat an eye. “I said ‘How certain are you that you’ll eat no more than 2 candy bars a day?’ ”

The woman started to cry. “You understand,” she said. “I’m eating 8 candy bars a day. During break, I went out to my car and ate 2 candy bars.”

For this particular diabetes patient, Lorig knew no formulaic management plan was going to succeed. The patient needed a solution adapted to her own situation, which a face-to-face encounter was able to uncover.

“She’s made a huge commitment,” Lorig said. “If I’d given her the lecture on carbohydrates at that point, I’d never have seen her again. It’s going for the real, not the ideal.”

In battling chronic diseases like T1DM and T2DM outside the hospital, researchers and doctors who spoke with Evidence-Based Diabetes Management agreed that intense involvement with patients is the key to success, though it often comes at a high price that cannot be sustained given the current structure of the healthcare reimbursement system.

Despite calls for value-based care, limitations in the reimbursement system still obstruct successful patient management, said Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform. Miller served as strategic initiatives consultant for the Pittsburgh regional health initiative from 2006 to 2010, where nurses were sent to the homes of people discharged from the hospital and were empowered to do what they, as nurses, thought was necessary to help the patients adhere to a recovery plan.

The chronic disease management program was a success, though it had to be funded through foundation grants as there was no established payment system under Medicare, Medicaid, or commercial insurance. There were no other standard medical servic-es revenue that could be tapped, Miller said.

“Nurses are trained to be able to help their patients, and the idea was let the nurse figure out what the problems were and what needed to be done about them, rather than being limited to do a specific kind of thing,” Miller said. The nurses encountered the same sorts of problems that Lorig sees in the Stanford self-management classes—problems that aren’t easily anticipated by a doctor sending a patient home from a hospital or divined by a nurse making a follow-up telephone call.

“One nurse who went to a home found that a patient had been using a nebulizer, and he was dutifully washing it every day according to instructions, but he was putting it wet into a plastic bag, which was a perfect breeding ground for bacteria,” Miller said. He added that he was aware of examples from similar programs in other parts of the country, such as a diabetes patient who couldn’t see properly to put the needle into his insulin bottle. “It’s hard to imagine all of the unique kinds of circumstances like that,” he said. “Many patients can’t read, can’t see, or can’t understand, and educational material alone may not solve the problem. They didn’t see it or they didn’t realize what it meant.”

The Pittsburgh project generated more savings in avoidable hospitalizations than the nurse intervention cost, Miller said, but the program only continues today because a local hospital was willing to pay for 1 nurse to continue making house calls. Other studies have shown that well-designed patient education and self-management programs can more than pay for themselves by improving patient outcomes, he said.

Diabetes, as a chronic disease, ranked third in 2011 for the number of Medicaid readmissions (23,700) behind schizophrenia (35,800) and mood disorders (41,600), according to the Healthcare Cost and Utilization Project.¹ CMS has not yet implemented formal readmission reduction targets, though some medical professionals wonder if that isn’t imminent, based on the direct medical cost of T1DM and T2DM expenditures, which amounted to $176 billion in 2012, according to a recent study by the American Diabetes Association.² Such targets could add more urgency to the quest to have patients take on more responsibility for managing their own health.

“Diabetes is infrequently the primary cause of readmission,” said Mary Korytkowski, MD, professor of medicine and interim chief of the Division of Endocrinology at the University of Pittsburgh. “It may eventually be recognized as a contributor to need for readmission, but is not currently a focus of many readmission prevention strategies.” Diabetes is often an underlying problem for many hospital admissions and readmissions, such as pneumonia, congestive heart failure, and vascular disease, Korytkowksi said. For this reason, whenever a patient comes into the hospital for what may or may not be a diabetes-related ailment, doctors and nurses need to know about this to allow analysis of the current level of glycemic control, as well as a patient’s ability to participate in recommended self-management.

In a T1DM and T2DM patient education program conducted in Pittsburgh, with results published in late 2013, Korytkowski and her fellow researchers concluded that a course of inpatient education could have positive effects on both short- and long-term patient health outcomes in this patient population. “The ability of patients with diabetes to achieve desired metabolic goals while reducing risk for long-term complications requires education in self-management practices with periodic reinforcement of these principles. For this reason, a program of diabetes self-management education (DSME) is recommended as standard of care for all patients with diabetes,” the report stated.³ The same report estimated that fewer than 50% of patients receive DSME, which puts them at increased risk for complications and hospitalization. Even so, the growing emphasis on self-management education today is a vast improvement from before, Korytkowski said.

Years ago, Korytkowski said, diabetes classes were held for hospitalized patients once or twice a week. These classes required patient attendance, which was not always realistic in those with acute medical problems. This resulted in poor attendance, she said. But patient education is one of the things competing for health workers’ attention and, as a result, it suffers the fate of many other prioritized needs, Korytkowski said.

“There’s so much attention now on limiting length of stay and just taking care of the issue that brought them into the hospital. So, say they have pneumonia: you treat the pneumonia, but the fact

that their blood sugar is off just doesn’t rise to the surface. The pace of things just doesn’t allow for all of these things that brought them to the hospital to be addressed.”

A multi-year study on an Australian population of chronic heart disease and T1DM and T2DM patients published in April 20134 weighed the value of repeated phone contact through the My Health Guardian (MHG) health maintenance program, which included followup with patients after discharge. “MHG proved to be an effective means to reduce the likelihood and duration of hospitalizations for individuals with diabetes and heart disease,” authors of the study wrote. “In this study, the MHG program demonstrated a consistent effect; treatment group members had reduced admissions, readmissions, and ALOS (average length of stay) relative to comparison group members....Furthermore, the magnitude of effect increased over time, demonstrating the importance of a sustained program for maximizing impact.”

While other researchers contend that face-to-face contact with patients outside the hospital is often essential to tailor diabetes management to individual situations, study coauthor Elizabeth Rula, PhD, said, telephonic management has a place in managed healthcare. “Diabetes is one of the conditions that is known to be very susceptible to improvement as a result of these programs,” said Rula, who is executive director and principal investigator at the Healthways Center for Health Research in Tennessee. Healthways is the provider of the MHG program that was studied. “We identified people who had recently been discharged or hospitalized, and tried to reach out to them,” Rula said. “That is a really critical point in time—you might call it a teachable moment—in terms of when someone is acutely aware their health is not optimally managed. So at that point, they can be amenable to the program and changes in how they are managing.”

In a prior study of telephonic followup for admitted patients with chronic conditions, nurse-delivered calls occurring within 14 days after discharge were associated with a 23% decrease in readmissions. From her work on this study, Rula saw the importance of timely follow-up, “because most readmissions occurred within 2 weeks of discharge, and a third within 1 week. Delays in identifying or reaching patients once they return home create missed opportunities to prevent a return to the hospital.”⁵

One of the barriers to the Australian program, however, was the limited amount of patient medical history information available, contrary to what US medical personnel generally have at their disposal, Rula said. Knowing more about patients’ medical history enables a more targeted approach in the telephonic program, she said.

“Typically we are able to model who is at highest risk for readmission, and reaching out to them is not a one-way push for information,” Rula said. “Here in the States, we often have access to a more robust picture of that person’s prior claims. When we’re working with health systems, we can actually get in up front and do an assessment of patients while they are in the hospital and start working with them at that point in time to allow early identification of that person’s needs and barriers that could result in a readmission.”

She said the potential of working with a patient before and after their care transition “is shown in our recent evaluation of the full model where we were able to initiate needs assessment and discharge planning in the hospital, which is then supported by telephonic follow-up.”

The success of the multiple phone call approach in the MHG study was not replicated in a study published this fall in Diabetes Care, where researchers found that a single scripted phone call to T2DM patients was not successful in getting them to adhere to the use of a new medication.⁶ A stated goal was to test whether this relatively inexpensive form of intervention would increase medication adherence, but the authors concluded: “This low-intensity intervention did not significantly improve medication adherence or control of glucose, blood pressure, or low-density lipoprotein cholesterol. Wide use of this strategy does not appear to be warranted; alternative approaches to identify and improve medication adherence and persistence are needed.”

Some believe the money spent on telephonic management is not wisely invested and actually diverts funds from more productive patient management and education initiatives. In Camden, New Jersey, the Camden Coalition of Healthcare Providers’ (CCHP) Care Management Program, Link2Care, has claimed a significant reduction in patient readmissions and nonemergent use of hospital emergency departments via the use of health teams who track patients from the hospital setting back into the community and provide support services that ensure that even patients’ housing needs are addressed. Targeting high-volume users of the health system, “A team of nurses, social workers, community health workers and health coaches, supported by data of healthcare utilization, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs,” according to program literature.

In Camden, where per capita income is significantly lower than in the rest of New Jersey, researchers were finding patients who not only didn’t have insulin, “They didn’t have food, their electricity was getting turned off, and they were significantly depressed,” all factors that contributed to their inability to manage their health conditions more successfully, said Jason Turi, associate clinical director of the CCHP. Such patients were among a population of 20% of hospital users who accounted for 90% of costs at 3 Camden hospital systems from 2002-2007. The team approach to care management was “found to improve health outcomes [and] decrease utilization of emergency and inpatient services and costs for a cohort of 36 ‘high utilizers’ from $1.2 million monthly to $534,000 monthly, a saving of 56% over 5 years.”⁷

“Part of the sustainability strategy for operations like ours and around the country is to reroute money away from telephonic management and into community-based operations,” because the belief is that community-based programs work better, Turi said. That is accomplished by working at the policy level, “actually getting to where care management dollars are going for publicly insured folks, especially Medicaid, to working here in New Jersey with our funders and with the Medicaid office to start rethinking what it means to do case management for complex patients.”

The program is currently the focus of a Massachusetts Institute of Technology proof-of-concept study that Turi believes will confirm what he considers the legitimacy of the approach and make funding easier to obtain. The program has already won a pay-for-performance contract from UnitedHealthcare, which administers Medicaid payments in New Jersey. “This is actually not a grant,” Turi said, “which is great. They pay us to service some of their more complex patients in Camden.”

References

1. Hines AL, Barrett ML, Jiang J, Steiner CA. Conditions with the largest number of adult hospital readmissions by payer, 2011. Rockville, MD: Healthcare Cost and Utilization Project, Statistical Brief Number 172. Agency for Healthcare Research and Quality; April 2014.

2. American Diabetes Association. Economic costs of diabetes in the United States in 2012. Diabetes Care. 2013;36:1033-1046.

3. Korytkowski MT, Koerbel GL, Kotagal L, Donihi A, DiNardo MM. Pilot trial of diabetes self-management education in the hospital setting. Primary Care Diabetes. 2014;8(3):187-194.

4. Hamar GB, Rula EY, Wells A, Coberley C, Pope JE, Larkin S. Impact of a chronic disease management program on hospital admissions and readmissions in an Australian population with heart disease or diabetes. Popul Health Manag. 2013;16(2):125-131.

5. Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. The impact of postdischarge telephonic followup on hospital readmissions. Popul Health Manag. 2011:14(1):27-32.

6. O’Connor P, Schmittdiel JA, Pathak RD, et al. Randomized trial of telephone outreach to improve medication adherence and metabolic control in adults with diabetes. Diabetes Care. 2014;37(12):3317-3324.

7. Healthcare Hotspotting in the United States. Poverty Action Lab website. http://www.povertyactionlab.org/evaluation/health-care-hotspotting-unitedstates. Accessed December 3, 2014.

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