CM program leverages resources in the community
Pharmacists are crucial part of case management
A community-based program that provides face-to-face care management for people with chronic disease has resulted in decreased health care costs, fewer missed days at work, and improved quality of life for program participants.
"The purpose of the program is to leverage resources that are already available in their community to help people learn to manage their chronic diseases," says Barry Bunting, PharmD, who was clinical manager of pharmacy services at Mission Hospitals in Asheville, NC, at the time of a pilot project and now is vice president of clinical services for American Health Care, a pharmacy benefit management and disease management company.
The Asheville project started as a pilot project conducted by the North Carolina Association of Pharmacists to determine if pharmacists could use their specialized skills and knowledge to help people with diabetes adhere to their treatment plan.
"Originally, we wanted to see if it would be of benefit for the pharmacists to spend this type of time developing a relationship and use their knowledge and skills to help people stick to their treatment plan. What actually happened was that people got the best medication for them and took it. It made a huge difference," he says.
Participants in the first phase of the pilot project were employees of the city of Asheville, covered by the city's self-funded employer health plan.
At the end of the pilot project, Mission St. Joseph Hospital, the largest employer in the area, decided to offer the disease management services to its employers.
As a result of the community-based interventions, two self-funded employer health plans saved more than $6 million in eight years, Bunting says.
The net decrease in total health care costs averaged $2,000 per patient per year for people with diabetes and $725 per patient per year for people with asthma, he adds.
Diabetics participating in the program decreased their missed work hours by 50%. For people with asthma, missed work hours decreased by 400%.
The employer's return on investment for diabetics was four to one, Bunting says.
The program has been so successful that it now includes 10 employers in Asheville for a total of 14,000 covered lives, Bunting says. Based on the success of the Asheville project, pharmacy associations in other states have created similar programs.
"The strength of our model is that it is community based and provides face-to-face contact. The personal contact allows the health care professionals who are serving as disease managers to establish a personal relationship with the participants and accomplish things that it would be much more difficult to do over the telephone," Bunting says.
Here's how the program works:
Employers offer the program to employees with chronic health conditions such as diabetes, asthma, hypertension, and high cholesterol.
The program is voluntary. The health plans agree to pay for medication and supplies and any copay the employees are responsible for as long as they are in the program.
"We have found that the program saves the health plan far more than the cost of the incentives. People in the program have far fewer hospitalizations and trips to the emergency department. The program makes a difference in their lives and lowers health care costs at the same time. It's a win-win situation for everyone," Bunting says.
People who enroll in the program agree to attend self-education classes covered by their company's health plan and meet face to face on a regular basis with a specially trained health care professional, either a pharmacist, a certified diabetes educator, or a nutritionist who becomes their case manager.
Participants initially meet with a pharmacist for medication assessment.
"Lack of medication adherence is a huge problem among people with chronic diseases. Patients often don't understand their medication regimen or they experience side effects and stop taking the medication. Pharmacists have the knowledge to help them understand their medications and to work with physicians to find alternatives that don't have side effects," he says.
Depending on his or her needs, the participant may be referred to a nutritionist, a diabetes educator, or in some cases a medical social worker.
"The program routes people to the resources they need to help them live healthier lives," he says.
Once the person is matched with a case manager, the case manager is responsible for setting a schedule with the participant. If the person doesn't show up for appointments, the case manager notifies the health plan administrator.
The case managers notify the participants' physicians about the program and their patients' participation and work with them to ensure that the treatment plan is being followed.
They monitor adherence and side effects, helping patients understand their treatment plan and helping them set goals, which may include exercise, diet, or smoking cessation.
They follow up on each monthly visit to find out if the participant met his or her goals for the month.
"Accountability is one of the reasons the program works so well. The pharmacist, nutritionist, or diabetes educator is someone the participant is accountable to. They set goals and report on them face to face. Being accountable to someone that they are going to see in person helps them be adherent," Bunting says.
To recruit pharmacists, the pharmacy organization sent a letter to all pharmacists in the Asheville area, offering a free training program in diabetes that qualified for continuing education credits.
Of the 24 pharmacists who came to the seminar, 18 signed up to participate in the pilot project and be compensated for their time.
"People who have knowledge about medications aren't spending the time they need to with people who need it. By compensating them for their time, we made it possible for them to do so," Bunting says.
The program benefits all participants, Bunting points out. The pharmacists are paid for their work with the patients. The health plan saves money. The patients receive their medication and supplies free, with no copay, and enjoy improved quality of life.
"We have found that when pharmacists, nurses, nutritionists, social workers, and diabetes educators work together, we can help people get their diabetes under control," he says.
A community-based program that provides face-to-face care management for people with chronic disease has resulted in decreased health care costs, fewer missed days at work, and improved quality of life for program participants.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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