Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Diabetes Management

01/01/2002

At the time of our visit, Kaiser Colorado had undertaken a pilot that was being evaluated for planwide implementation. It was staffed by two nurses who devoted nearly full time to the pilot. A diabetes registry has been developed, and a risk stratification process has been implemented to identify enrollees who need special attention, including one-on-one counseling. Risk factors that are tracked through the registry include (1) high hemoglobin A1c test results, (2) no evidence that tests were conducted, (3) repeated emergency room and inpatient use, (4) no evidence of an LDL (cholesterol) test in the previous two years, and (5) no diabetes-related visit within the previous year.

These two nurses provide patient education and proactively call on members at high risk. Reflecting Kaiser Colorado’s objective to improve medical practice quality, outcomes are tabulated for each primary care physician and are shared within the clinic, with the names being listed, thereby letting each physician know how he or she compares with colleagues. Measures include hemoglobin A1c test results, percentage of patients with eye exams, LDL levels, and urine protein levels. Empirical results of the pilot, based on both a comparison with nonparticipating clinics and analysis of performance before and after the pilot, reveal significant improvements in a number of measures, including better hemoglobin A1c control, more foot care, and higher member satisfaction. The health plan intends to expand the program to other sites.

The program at HMO Oregon entails less direct contact with the patient. PCPs receive mailings listing patients for whom there is no record of hemoglobin A1c tests, and patients are surveyed to inquire if they have had foot exams. Also, a pamphlet on self-care is sent to diabetics, along with a wallet card that provides a checklist of medical tests that should be performed. A diabetes registry is being developed. A sample of 800 members who were surveyed before and after the intervention experienced significant increases in the number of members reporting having had their eyes examined during the year, self-performing foot exams, performing blood glucose testing, and correctly identifying the purpose of the hemoglobin A1c test.

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