1 ADVANCE for Executive Insight

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DIABETES The nursing case management approach has paid off handsomely. At each 3-month assessment, at least 60 percent of the clients demonstrated a statistically significant decrease in A1c levels, and only 25 needed additional improvements. with cognitive impairment or depression,” explained Kathleen Falk, MSC, FNP, assistant professor at New York City College of Technology and chairperson of the ADHC study. “It’s important to identify how we can best use our nursing resources to help them stay in the community with support,” Falk emphasized. “To control their A1c levels is a very significant accomplishment.” Easy as A-B-C A structured care plan established the foundation for individualized diabetes management. “While a nurse could easily become sidetracked by a hypertensive crisis that requires immediate intervention, for example, the ABCs of the care plan cues the nurse to look at the whole picture after the crisis is resolved,” Falk said. “People don’t generally die of diabetes — they die from cardiovascular events. The care plan affirms the value of nursing care coordination in bringing together the diabetes team with a conference call.” Falk emphasized the importance of identifying barriers to treatment, rather than labeling clients as noncompliant. “We have an interdisciplinary team for a reason, and a client’s barriers to care can go unaddressed if the nurse doesn’t make appropriate referrals,” she said. “We were able to make headway by providing the nurses with education about identifying and managing depression, helping them understand that depression presents differently in the elderly, or that culture plays a role in how depression is expressed. “Once we suspect depression, we further assess with symptom rating scales and make referrals to team disciplines such as social workers, psychologists, and psychiatrists.” The nursing case management approach has paid off handsomely. At each 3-month assessment, at least 60 percent of the clients demonstrated a statistically significant decrease in A1c levels, and only 25 needed additional improvements. Data analysis demonstrated the effectiveness for the group as a whole. Population Management Lory Dahlhauser, RN, CDE, a diabetes case manager at Kaiser Permanente’s Stockton, CA medical offices, described the three-level population management model that her health maintenance organization has adopted for members with diabetes. “Level 1 members are newly diagnosed and attend classes while their primary doctor manages their diabetes,” she said. “Level 2 patients have high A1c levels (above 8.5 percent) and receive telephonic assistance from RN or RD care managers for 6 months to a year to lower their A1c levels, blood pressure and cholesterol. “All members with type 1 diabetes, members in renal failure and on dialysis, pregnant women, children with diabetes, and members on insulin pumps from our office are referred to me for case management.” When she receives a new referral, Dahlhauser calls the member directly to set up an initial appointment. “I establish right away that we’re going to work together to keep them safe and their disease under good control,” she said. “I personalize the approach to target an A1c at a certain level, without incidents of hypoglycemia. “The rule of thumb is 7 percent, but members who are older, have complications or experience significant hypoglycemia, may be encouraged to keep their A1c target closer to 8 percent.” Dahlhauser makes good use of the Kaiser Permanente website and the Internet for two-way communication with members. “I have a lot of patients who e-mail me, and 42 ADVANCE for Executive Insight
DIABETES that works well since I’m on the computer constantly,” she said. “Once I’m on their provider list, they can send me messages and ask questions. “A member may send me blood glucose results, for example, and I can review them and make an immediate change in insulin dosage. Insulin pump companies also sponsor a web-based computer program that allows me to use the member’s password, review blood glucose trends and then email instructions.” Telephonic Case Management Jody Pankow, BSN, RN, diabetes case manager at Physicians Plus Insurance Corporation, Madison, WI, recently transitioned to telephonic case management from her previous role as a diabetes educator in an ambulatory care center. “I’ve been reviewing the files on members who received diabetes case management over the past year, and found some real successes,” she said. “A lot of members started out with an A1c greater than 8.5 percent, 9 percent or even 10 percent but are now down in the 7 percent range.” Seasoned diabetes case managers understand the importance of identifying the knowledge level, learning readiness and self-efficacy beliefs that drive different individuals who have diabetes. “The first group is made up of people who need a little extra motivation from someone who isn’t their physician or healthcare provider,” Pankow said. “They need someone to say, ‘You can do this’ and then they will take the bull by the horns, institute healthy lifestyle changes, improve their blood glucose levels and sustain their goal A1c over time.” The second group needs more consistent follow-up from their case managers. “These are the members who start at 8 percent, go up to 9 or 10, drop down again and see-saw back and forth,” Pankow said. “They do well with constant reminders, reinforcement and someone to hold them accountable. As soon as you say, ‘OK, you’re doing good! Let’s touch base again in a month,’ they go off track.” The third group does best in a collaborative relationship with the diabetes case manager. “These members tell me, ‘I know what to do, I just need to do it!’” Pankow said. “I work with them to identify issues and barriers to effective glucose control. Together, we explore telephonically and come up with strategies that work for the individual.” Staff members at Physicians Plus are in the process of obtaining accreditation for the diabetes case management program from the National Committee for Quality Assurance, NCQA. “We track HEDIS data about patient outcomes, including the A1c values,” Pankow said. Don’t miss these upcoming issue features: FREE digital subscription. FREE online resources. FREE access to so much more. • Waste Stream Management • The Value of IT • Solutions for Supply Chain/Materials Management • Top IT Predictions for 2013 • The Lab as a Profit Center • Special Reader’s Choice Edition Don’t miss these upcoming online features: • Cost Containment • Supply Chain Management Webinar • Mobility in Healthcare • Making Sense of Analytics • Managing an Effective Workforce Webinar • Healthcare Reform Don’t miss all that Executive Insight offers! Become an Executive Insider today. • Visit www.advanceweb.com/executiveinsight • Snap the tag to the right Strategies and Solutions for Healthcare Leaders ADVANCE for Executive Insight 43
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