Disease Management Advisor, May 2008

Inside:

Interim report shows clinical improvements for diabetes initiative

First SNP for Alzheimer’s disease implemented

Multidisciplinary team key to chronic care

Active seniors decrease health costs

WellDoc pilot shows clinical improvements in diabetics

Interim report shows clinical improvements for diabetes initiative

Pharmacists, VBID keys to program

The Diabetes Ten City Challenge (DTCC), which uses pharmacist coaches and a value-based insurance design (VBID) to help patients manage chronic disease, demonstrated improvements in all key clinical indicators in the first year, according to an interim report by the American Pharmacists Association (APhA) Foundation.

Through the DTCC, which the foundation is conducting in 10 U.S. cities with support from GlaxoSmithKline, employers establish a voluntary health benefit for insured members with diabetes and waive copayments for diabetes medications and supplies if they work with a pharmacist coach to manage their condition. The DTCC is modeled after other APhA Foundation programs that have proven to improve overall health, reduce absenteeism, shorten hospital stays, and reduce healthcare costs.

The interim report, published in the March/April Journal of the American Pharmacists Association, reviewed results of 914 patients who were in the DTCC at least three months as of September 30, 2007. It documented improvements in all the recognized standards of diabetes care (see the chart on p. 3 of the PDF of this issue), including:

• Clinical measures, such as A1c, LDL cholesterol, and blood pressure
• Care measures, including current influenza vaccinations and foot and eye exams
• Self-management goals for patients, such as nutrition, weight, and exercise
• Patient satisfaction with their pharmacist and overall diabetes care

Coauthor of the report William M. Ellis, CEO of the APhA Foundation, which contracts with employers, helps establish local pharmacist networks, and provides software and data analysis for the DTCC, says the diabetes self-management program empowers patients and puts them at the center of care. “Too many times, patients really are not directly involved in their care. With this program, they become educated about their condition and work in partnership with their pharmacists, physicians, and other healthcare providers,” says Ellis.

Building upon the Asheville Project, a successful pharmacist-driven diabetes program implemented in Asheville, NC, the APhA Foundation is expanding the pharmacist coach model nationally to prove it can be replicated in diverse geographies and various employer types.

The project is the most recent initiative giving the pharmacist a greater role in healthcare. A study released earlier this year by the University of Oklahoma Health Sciences Center’s College of Pharmacy in Oklahoma City showed that pharmacists performing medication therapy management services improved diabetic patients’ A1c levels. (See the February DMA for more information on this study.)

Although many graduating pharmacy students have healthcare experience beyond dispensing pills, local pharmacists are a largely untapped resource by the healthcare system, says Ellis.

The DTCC creates a system in which pharmacists play a larger role. There is also greater communication among the physician, diabetes educator, and other healthcare professionals. The pharmacist coach combines teaching lifestyle factors, such as prevention, exercise, and reading labels, which are meant to empower the patient to take a greater role in his or her health, with a clinical component in which the pharmacist can review and suggest changes to medications and check blood sugar and A1c levels. Jan Park, RN, a wellness coordinator for the city of Charleston, SC, says the pharmacist plays the role of patient advocate and collaborates with the physician and other members of the care team.

Pharmacists are also able to spend more time with patients than PCPs, who are often stretched for time. “They feel like their pharmacist coach is someone they can definitely call at any time and is a little bit easier to get in touch with at a moment’s notice and get their questions answered rather than waiting for their physician,” says Park, adding that one-third of the city’s diabetic employees (89 people) took advantage of the program.

Charleston doesn’t have the clinical outcomes for its DTCC patients, but Cecily V. DiPiro, RPh, PharmD, a pharmacist at The Prescription Center in Charleston, says, overall, her patients have started exercising more, reduced blood sugar and A1c levels, and are feeling better.

The city hasn’t received the insurance claims data yet to review the potential program savings, but Park hopes to save at least $1,000 per year per participant, which she bases on the Asheville Project. “It’s really an amazing thing to see. It really makes you feel like we’re doing something to help change healthcare,” says Park.

The preventive nature of the program is what prompted Charleston officials to get involved. The U.S. healthcare industry is great at “fixing things after they’re broken,” but DTCC is a shift to prevention focus, Park says.

“We need to shift [healthcare] over to more prevention and putting people in control of their disease and educating them and giving them the tools they need to prevent complications,” Park says. That shift to prevention appears to be working in the DTCC. After one year, the report noted, the program showed the following improvements:

A 21% increase in the number of participants achieving the American Diabetes Association goal of A1c levels of less than 7%

An increase from 43.8% to 57.7% of those who achieved National Cholesterol Education program goals for LDL cholesterol

A 15.7% increase in the number of people who achieved recognized goals for systolic blood pressure

The study’s authors say programs such as the DTCC could affect how healthcare is delivered in the United States.

“Successful implementation of such a model on a broad scale would have the capacity to transform the healthcare system by improving outcomes and controlling costs,” according to the interim report.

The ten DTCC sites are:

• Charleston, SC
• Chicago
• Colorado Springs, CO
• Cumberland, MD
• Honolulu
• Milwaukee
• Northwest Georgia
• Pittsburgh
• Los Angeles
• Tampa Bay, FL

Training

Pharmacists participating in the DTCC completed a diabetes certificate program offered by the APhA. This program reviewed diabetes and its complications, offering management, monitoring, and educational strategies for diabetes care, as well as information on exercise and nutrition.

DiPiro assists in the care of 30 patients in the DTCC and says her role is to keep the patient focused. “The majority of these people know what they need to do. They know that they should be eating better, that they should be exercising more, but they need that one more person to keep them focused on actually doing it and someone to be accountable to,” she says.

Pharmacists meet with diabetic patients four times in the first six months. The first visit includes collecting information about medication, disease history, exercise regimens, sugar levels, and other specifics so the pharmacist knows where to focus. After that, visits range from 30 to 60 minutes and vary in regularity, depending on the status of the disease. For the patient who is in control of his or her diabetes, a meeting every three months might be sufficient, but someone with more education needs may have a monthly visit.According to the report, the participants studied visited the DTCC pharmacist an average of 4.6 times in the first year. During those appointments, pharmacists reviewed patients’ medications and blood glucose self-monitoring skills. A1c and cholesterol test results were discussed, when available, and pharmacists taught patients about nutrition and helped them create clinical, fitness, and nutritional goals.

Patients are weighed at every visit and the pharmacist also takes their blood pressure. The pharmacists are reimbursed by employers for patient visits depending on the fee schedules negotiated by the local pharmacy network.

DiPiro says part of her role is empowering patients to take greater control of their healthcare, such as suggesting what questions to ask a physician. For example, many of DiPiro’s patients did not understand or request copies of their blood work before the DTCC.

“It has been very gratifying to see people now ask, ‘What was my A1c?’ or ‘How do my cholesterol values look?’ ” says DiPiro.

After each visit, the pharmacist sends a note to the patient’s physician with a summary of the visit. The pharmacist might also call the patient’s physician if there is a concern. Clinical information obtained at each visit is documented by the pharmacist at a secure Web site.

Some physicians have been leery of programs in which other healthcare professionals assist in patient care, but DiPiro says she has not received any pushback from physicians.

She adds that she is careful not to compromise the physician-patient relationship. When communicating with physicians, she says she stays focused on the issue at hand and lets physicians know she is there to work with them.

“I want my patients to have the best relationship they can with everyone on the team because we are all working toward the same goal,” says DiPiro.

Park says physicians in the Charleston area have been receptive to the DTCC and have even encouraged some of their diabetic patients to take part. The pharmacist coaches’ participation has increased doctor visits because of prevention.

“Visits with the pharmacist coaches are not in place of their doctor visits. The nice part of the physician visit is they are becoming more preventive,” says Park, adding that physician visits before the DTCC were related mostly to sickness rather than prevention.

Ellis says the process of care is changing with more acceptance of pharmacists as members of a collaborative healthcare team.

“The pharmacist coach is central to this model, but not at the exclusion of other healthcare providers. This program involves a lot more communication and referrals to physicians, diabetic education centers, and other healthcare professionals than typically is found in the care process,” says Ellis.

DiPiro says the DTCC has allowed her to collaborate with other pharmacists on matters such as patient interviewing techniques. She takes a greater role in a patient’s care in the DTCC, asking personal, open-ended questions about general health, caregivers, and whether the patients have received eye and foot exams. Although pharmacist coaches are not the norm for community pharmacy, DiPiro says pharmacists in institutional practice have had more opportunity for involvement in direct patient care as members of the healthcare team.

“The opportunities at the community level can only expand. There are so many chronic diseases, and I believe pharmacists can have an impact in improving a patient’s daily health,” says DiPiro.

Researchers will review the economic analysis for the DTCC (which has expanded to more than 1,000 participants and 31 employers since the interim report research was conducted), and Ellis hopes to release that information in the first quarter of 2009.

Business leader: The DTCC involves best practice strategies

Not only are patients, their families, and the healthcare system struggling with the $174 billion spent annually on caring for the 17.5 million diabetic Americans, but businesses grapple with an estimated $58 billion in reduced productivity and absenteeism each year.

The authors of the Diabetes Ten City Challenge (DTCC) believe that the program, which couples a pharmacy program with a value-based insurance design (VBID) model that reduces or eliminates copays on specific drugs—in the DTCC’s case, diabetes drugs and tests—could be the cure for what’s ailing diabetic care.

“By implementing this standardized model, employers in a variety of markets can improve health outcomes for their health plan beneficiaries with diabetes,” according to the interim report published in the March/April Journal of the American Pharmacists Association.

Andrew Webber, president and CEO of the National Business Coalition on Health in Washington, DC, says his organization supports the DTCC and also backed the Asheville model, which was the launching point for the DTCC.

Webber’s organization believes that the idea of empowering patients through greater pharmacist involvement coupled with VBID combines best practice strategies. “There is a very good chance that this chronic condition can be managed, and individuals can live with diabetes and be very productive members in an employer’s work force,” says Webber.

Beyond a moral obligation, Webber says employers have a “huge business imperative” to tackle the issue of diabetes-related costs. Webber, a VBID proponent, says cutting copays gives employees an incentive to join the DTCC and shows that businesses support prevention and chronic care DM. The VBID model has been gaining popularity as studies have shown the benefits of reducing or eliminating copays for lifesaving medications. One study, released in January and led by a team of University of Michigan and Harvard University researchers, echoed other studies that reported that incorporating a VBID can increase medication compliance. That study of a large private employer showed significantly increased employee use of chronic-disease medicines by reducing or eliminating copays.

Another recent study by Brown University and Harvard Medical School researchers published in the New England Journal of Medicine showed that significantly fewer women received mammograms if a copay was charged for the potentially lifesaving screenings.

VBID supporters say the model works well with a DM program. In a regular DM program, coaches impart knowledge, but patients may not follow it because they can’t afford prescriptions. “Here’s an area where some short-term investment has longer-term payoffs on the two outcomes most important to employers: It improves their health and productivity and controls overall costs,” says Webber.

In the DTCC project, Cecily V. DiPiro, RPh, PharmD, a pharmacist at The Prescription Center in Charleston, SC, says the waived copays have increased diabetes medications and testing, which she believes will improve outcomes and reduce long-range costs.

“We see the wisdom in spending that money on prevention versus later having to spend that on a complication of diabetes,” says Jan Park, RN, a wellness coordinator for the city of Charleston.

Webber says he hopes the DTCC model of proactive community pharmacist coaches is the future of healthcare, adding that he would like to see the notion of the community pharmacy transformed from a place to pick up drugs and buy groceries to one of a community health center.

Community pharmacies should welcome these kinds of programs, and pharmacist coaches could work well as a business model, Webber says. Community pharmacies often compete with mail order companies, and pharmacy benefit managers often bypass the local pharmacist. By taking a larger coaching role, community pharmacists can create their own niche, he says.

“I would even argue that there is a business imperative to rethink their role at the community level,” says Webber.

First SNP for Alzheimer’s disease implemented

This is the second article in a two-part series exploring Medicare Advantage special needs plans (SNP).

Evercare rolled out a Medicare Advantage SNP in January designed specifically for people with chronic disease and dementia.

Medicare has agreed to pay for services that help the caregivers of these patients, not the patients themselves. The program also includes direct collaboration with Banner Alzheimer’s Institute in Phoenix, which helps families dealing with dementia.

“In Arizona, we are taking care of many patients with dementia and chronic disease,” says Ana Fuentevilla, MD, medical director at Evercare’s Arizona region. “Before we initiated this program, there was a huge burden for caregivers that was not being attended to and that had a direct impact on our ability to provide optimal care for the patients.”

Fuentevilla and her colleagues sought the advice of the Banner Alzheimer’s Institute in developing a specific benefits package that would meet the needs of these caregivers. Within three months after proposing the plan to CMS, the government approved this first SNP for Alzheimer’s disease, she says.

The program targets all stages of the disease, including late-stage dementia when DM strategies are most difficult to implement because of the beneficiary’s cognitive impairment.

Key elements of the program are education for caregivers and members, care manager coordination, special prescription drug coverage for dementiarelated therapies, free enrollment in the Alzheimer’s Association Safe Return program (a program that helps families find a loved one who wandered from home and got lost), and emergency respite services that provide caregivers with a break so they can address their own healthcare needs. Another added benefit to caregivers is free transportation for up to 10 one-way plan-approved trips per year.

“We looked at the traditional benefit package for a special needs plan and added a couple of additional benefits for this population,” says Fuentevilla. For example, the drug benefit includes the memory drug Aricept on the formulary, but it also includes it in a lower tier so that the out-of-pocket copay expense for families is less, she says.

Professional care managers lead team

“Our care managers are essential to helping members and families navigate the maze of the healthcare system,” says Fuentevilla. Care management is very intensive, with an assessment scheduled with the member and family immediately after enrollment in the SNP program.

“This is a two- to three-hour meeting in which we help caregivers assess the member’s current status and help the families understand and anticipate decline,” says Julie Keys, LMSW, clinical manager of the Alzheimer’s disease special needs program. “Our care team, unlike other disease management care teams for Medicare patients, must be experts in dementia care.” Each care manager receives specialized training from the Banner Institute.

“The goal of our care managers is to be both preventive and proactive,” Keys says.

She cites an example of a patient who has started to exhibit behavior changes that include combativeness or paranoia. “These are two common situations with dementia patients,” she says. “We prepare the caregiver through education that explains what is happening to make the patient act this way and strategies for reacting to and managing it.”

The in-home meeting and subsequent visits (as needed by the caregiver) allow the care manager to identify triggers in the home that might lead to difficult-to-manage behavior. For example, if the person with dementia is talking to imagined people, the solution may be as easy as taking down all mirrors and pictures in the house, says Keys. The eight-week educational program for families allows care managers to share techniques they have learned at Banner with caregivers.

Membership in this SNP also provides families and patients with the opportunity to visit with a dementia specialist at Banner to evaluate conditions and develop a care plan and to participate in clinical trials if they are interested.

Physician collaborators

“It is really important for the patient’s primary care physician to understand that this program is not a replacement but rather a collaborator,” says Fuentevilla. “Our care managers work closely with the physician, particularly in managing the member’s other chronic illnesses.”

Fuentevilla says Medicare beneficiaries in this program will undoubtedly have other chronic diseases, such as diabetes and CHF, that must be managed as part of an overall chronic care plan. “What we are doing with the Alzheimer’s program is incorporating these services into the chronic disease model,” she says.

Multidisciplinary team key to chronic care

Proof that DM/chronic care management can be effective in the older, sicker population of Medicare patients might be found in small programs rather than in large programs such as Medicare Health Support.

Take, for example, a three-year demonstration called After Discharge Care Management of Low Income Frail Elderly (AD-LIFE), a program funded by the Agency for Health Research and Quality (AHRQ) that’s now entering its third year in Akron, OH. The goal of the initiative is to reduce hospital readmissions and nursing home placements, as well as overall functional decline and decreased quality of life.

“We haven’t been allowed to look at the actual data as yet, but all of the anecdotal findings point to the fact that the team approach is improving the quality of health for the patients enrolled,” says Kyle Allen, DO, a geriatrician and medical director at Summa Health System in Akron and principal investigator of the AD-LIFE study.

A smaller pilot study done at Summa Health before the AD-LIFE trial included 118 patients. It showed that the intervention of a multidisciplinary care team that focused on individual management of patients with more than one chronic disease resulted in decreased hospital admissions and decreased costs.¹ The pilot compared the cost of prehospitalization with a one-year post-care management implementation. The results showed a savings of approximately $1,000 per patient per month, says Allen.

So far, the AD-LIFE trial has enrolled 300 patients with a goal of 533 by the end of this year. In many ways, the design of this trial would seem to defy all previous theories about what population is most likely to improve with individualized care management. Patients in this trial are all low-income and are Medicaid eligible and nursing home certifiable. They must have more than one comorbid condition, have posthospital discharge complications, and be limited in at least one activity of daily living (e.g., feeding, bathing, or dressing) or two instrumental activities of daily living (e.g., preparing meals, taking medications, or grocery shopping).

Patients must be able to return home after discharge or after a short stay in long-term care. In addition to these inclusion criteria, patients are tested for cognitive impairment. Allen says although mild dementia doesn’t prohibit patients from being able to benefit from the study intervention, moderate and severe dementia would be an excluding factor in enrollment.

“The diversity of people enrolled in the program so far is amazing,” says Kathy Wright, MSN, RN, APN, BC, coinvestigator of the trial. “There are so many examples of patients referred to the study who were homebound or who had one foot into a nursing home and now are living independently,” she says.

Many of the patients had psychosocial issues, such as caregiver support and geriatric syndromes, including incontinence, depression, and dementia. Wright and Allen say these issues, and other intangibles that make it harder for these patients to be more self-directed, are often present in older Medicare patients. But, they say, these issues are often not accounted for in DM programs that focus more on the disease than the individual person.

“These patients need a navigator, either a registered nurse or a social worker, tied to a multidisciplinary team that manages patients with higher disease risk and higher utilization of services,” says Allen.

And that’s what the AD-LIFE trials provide—each enrollee is followed by a case manager who is part of a multidisciplinary care team that includes a geriatrician, an RN, a pharmacist, and a social worker. Other specialists, such as occupational, physical, and speech therapists, might be added to the team if necessary.

Allen says medication management is a key to the management of these patients, adding that many chronically ill patients who are on a host of medications end up having a medication-related adverse event that puts them back in the hospital within a few weeks after discharge. A key member of the team is the geriatric pharmacist who does a review of all of the patient’s medications.

Intervention elements

AD-LIFE trial patients are referred to Summa Health by the local Area Agency on Aging (AAoA) for frail elderly. Wright says the trial uses the social services of the AAoA (e.g., home health aides, transportation, mobile meals, portable weight scales), but adds on the elements of a comprehensive geriatric assessment, the care management team, an individualized evidenced-based care plan, and a focus on patient self-care and education about their chronic illness. The patients are followed for one year after hospital discharge.

The implementation of the care management begins while the patient is still in the hospital to improve the transition between inpatient and outpatient care, Wright says. The care manager does the in-home assessment within one week of discharge and develops and implements a care plan that is shared with the patient’s PCP. Other tasks that the care manager performs include:

• Ensuring access to medical and social services
• Educating the patient about signs and symptoms of chronic illness exacerbation and appropriate response if symptoms occur
• Informing and motivating the patient about lifestyle changes, such as smoking, exercise, alcohol consumption, and diet
• Ensuring medication appropriateness
• Ensuring continuity of care by communicating with all medical and social service personnel who interact with the particular patient

Case managers meet with the PCP to discuss the one-page care plan, which serves as an icebreaker between the nurse and doctor. “This is different than traditional disease management, in which doctors are bombarded with case managers who they feel are interfering with their management of the patient,” Wright says.

Allen says Summa Health System doctors benefit from the case manager, and physicians see the “AD-LIFE participation as a downstream benefit and true resource.”

Self-motivation is important in this patient population. “Since these patients are low-income, there is a certain social reluctance to take on a more direct role in their own care,” says Allen. “In many cases, they have never been asked to challenge low expectations about their own healthcare.”

Wright says case managers let the patients set their own goals. They help the patient develop and keep personal medical records, including a living will and advance directives for healthcare.

“Educated patients bring all of their medical information and a list of medications to each doctor’s visit and keep medications organized to prevent errors,” Wright says.

“They learn to know their own body, be alert to changes, and know how to distinguish between non-urgent and urgent needs … They also know that if they don’t understand medical terminology, they should not hesitate to ask questions,” she adds.

Allen says the trial has helped patients who came into it just trying to survive and has improved health disparities and health literacy.

The program allows for more one-on-one time with the patients, Wright says, citing an example of a woman who had to use a motorized scooter when she enrolled in the trial.

The woman was close to needing nursing home care because of her immobility. She started taking water therapy classes, lost 25 lb., and no longer needed the scooter.

Trial patients now initiate calls to the doctor’s office to report a symptom or ask for test results, says Wright. “They don’t have a wait-and-see attitude anymore,” she adds.

Allen says the trial is funded by AHRQ through October, but he hopes to get additional funding to perform another full year. The additional 12 months of data will help verify that these interventions are working, he adds.

Reference

1. Wright, K, Hazelett, S, Jarjoura D, and Allen K. “The AD-LIFE Trial: Working to Integrate Medical and Psychosocial Care Management Models.” Home Healthcare Nurse 2007; 25(5):308–314.

Active seniors decrease health costs

SilverSneakers study shows significant benefits in year two

Being physically fit improves a person’s well-being and reduces mortality, and a recent study shows that a fitness program for senior citizens can control healthcare costs.

The study, “Managed-Medicare Health Club Benefit and Reduced Health Care Costs Among Older Adults,” was funded by the Centers for Disease Control and Prevention (CDC) and conducted by Group Health and the University of Washington, both in Seattle.

Researchers studied nearly 5,000 SilverSneakers participants, who are Medicare Advantage beneficiaries, over a two-year period. The retrospective cohort study discovered that total healthcare costs and inpatient admission costs increased at a smaller rate among SilverSneakers members than the control group. (For a breakdown of healthcare costs, office visits, and inpatient admissions, see the chart on p. 8 of the PDF of this issue.)

Steve Lindstrom, vice president of the Arizona Business Unit at Healthways in Tempe, AZ, says the study is important because health plans and Medicare are demanding positive ROI for wellness programs. The SilverSneakers study, which was published in Preventing Chronic Disease, a peer-reviewed electronic journal published by the National Center for Chronic Disease Prevention and Health Promotion, one of CDC’s eight centers, shows the ben