Diabetes Coordination Program a Lesson in Rural Innovation

We hear a lot these days about the challenges facing rural healthcare providers.

Those challenges are real and daunting. They include accessing technology and capital, finding qualified clinicians and other skilled healthcare workers and technicians, and providing access and wellness strategies for a population mix that can often be disproportionately poor, uninsured, unhealthy and isolated.

We should not forget, however, that rural healthcare providers are also creating innovative programs to overcome these many obstacles. These rural healthcare professionals are not sitting back waiting for someone else to solve their problems.

For example, Choptank Community Health System's six federally qualified health centers serving isolated communities along Maryland's Eastern Shore is using a $400,000 two-year grant from not-for-profit CareFirst BlueCross BlueShield to develop an intensive intervention program for noncompliant Type 2 diabetes patients.

CCHS believes the program will pay for itself with healthier diabetic patients requiring fewer emergency interventions and hospitalizations.

John R. Strube, CCHS's vice president of marketing and development, told HealthLeaders Media that most of the grant money will pay for two fulltime nurse coordinators to aggressively monitor treatment regimens for about 250 patients "whose A1Cs are seriously out of control."

"Diabetes is one of those illnesses that if you manage it well, you prevent a lot of damaging and expensive health problems, because the disease really does attack your whole system," Strube explained. "One of the challenges particularly for folks in the safety-net world or folks who have limited coverage is getting them involved in the kind of really intensive care you need to manage or prevent diabetes."

"The opportunity from CareFirst was particularly intriguing for us because they are focusing on doing things at the primary care level to manage chronic and multi-symptom diseases effectively and at a more cost-effective point in the care delivery system than having folks show up in the hospital in severe shape."

In addition to the individualized treatment plans and close monitoring, the intervention program will use group-centered disease management tactics that rely on peer support to maintain treatment regimens.

"Most insurance companies don't cover that very well but we made it clear to CareFirst that if this model works would you consider adapting your reimbursement model to cover this? They said yes," Strube says. "There is a real excitement about the partnership we are building."

CCHS will also use some of the money to devise financial incentives that will reduce care costs for the diabetes patients who maintain that regimen and meet health improvement markers. 

"Part of what we are trying to do with this grant is to look at the problems our diabetic population faces and say if you join the program and are compliant and we see progress we will provide some form of incentive that, for example might help you offset the cost of your co-pay," Strube says.

About 80% of CCHS's 27,700 patients are at least partially insured, but that doesn't mean their costs are covered. "We have a fairly balanced case mix but a significant portion of our patients are economically distressed."

With the region facing tough economic times, Strube says it makes sense to offer financial incentives in a pilot program to keep cash-strapped diabetic patients on their regimen. "We offer greatly reduced costs for folks who don't have insurance, but it is not free," he says.

"Even for folks who have insurance, many employers are going to high deductible plans. So the first $1,000 might be out of their own pocket. When gas is $4 a gallon and you have to drive to get anywhere around here because there is no public transportation, people are oftentimes putting their co-pay in the tank to come and see the doctor."

What happens in two years when the CareFirst grant money runs out?

"Once the funding goes away we will have to look at how we can maintain an incentive program. That is the one wildcard in all of that," Strube says. "Our hope is that as we are able to demonstrate this we will along the way become certified as a diabetic education site with the American Diabetes Association. That will help us provide a service that is reimbursable with insurance. By capturing that reimbursement we should be able to sustain the program post grant."

Strube believes that a successful diabetes intervention program could also serve as a blueprint for treating other chronic diseases. All of this would help to reduce spiraling healthcare costs and alleviate other challenges that chronically understaffed and underfunded rural healthcare providers face.

"For our uninsured population, we don't generate a lot of revenue. The savings are to the system, not necessarily to us. Along the way, if we can show that we are bending the cost curve, we share in those savings," Strube says.

"The key thing is we know that if we can engage the patients and their families in making the investment to do the things they need to do, we know their health will improve."