Diabetes program emphasizes team approach
Improved quality of life is top priority
Patient education and a team approach to coordinated care are the cornerstones of a new diabetes management program started by Prudential HealthCare, a division of Newark, NJ-based The Prudential Insurance Company of America.
The program, now in a pilot phase with Prudential health plans in North Texas and Oklahoma City, seeks to contain costs and improve the quality of life for patients with diabetes. The disease went to the top of Prudential's list for potential disease management programs when company officials realized how much more expensive and devastating to patients' lives diabetes is than other illnesses, says Patricia Barta, MPH, RN, CDE, manager of health management programs for Prudential.
"Diabetes was by itself at the top of the list, with the next disease falling way below it," Barta says. "Diabetes takes one out of every seven health care dollars. It's just a very, very expensive disease, and the quality of life for people who are poorly managed is really poor."
Prudential came up with a set of guidelines for physicians to follow based on the American Diabetes Association's clinical practice recommendations:
· measurement of glycated hemoglobin levels;
· measurement of LDL cholesterol levels;
· counseling and care for pregnancy in women with diabetes;
· proteinuria screening and prevention of renal failure;
· retinal eye examinations;
· smoking cessation;
· regularly schedules diabetes assessment visits;
· blood pressure measurement and control with ACE inhibitors, unless contraindicated;
· foot examinations;
· weight measurement and control;
· low-dose aspirin intake.
Educator assesses learning needsIn a manual on the program given to participating physicians, each of the above recommendations is explained in detail with supporting references. "They're obviously not things pulled out of someone's hat; they can be backed up in the literature, so we included that," Barta says. The manual also includes a list of diabetes drugs, a list of diabetes resources, and a list of what services and supplies Prudential covers. (See sample list, inserted in this issue.)
But Prudential knows that physicians don't have the time to do the kind of education and counseling that diabetes patients need, so one of the highlights of the program is a team approach.
Patients who fall within target levels on such measurements as blood lipids and blood sugars continue on their usual course of treatment; however, patients who aren't under control - identified through hemoglobin A1C readings, hospitalizations, and diabetes-related complications - are referred to a diabetes educator and dietitian. The educator assesses the patients' learning needs, identifies gaps in their skills, and empowers them to self-manage the diabetes. The dietitian develops a meal plan specifically for that patient.
Case management model proves successfulAs part of the education program, patients also receive brochures on self-management, general diabetes information, foot care, and smoking cessation. One brochure, called "Your Guide to Leading a Healthier Life," gives patients contact information for national resources such as the American Diabetes Association in Alexandria, VA, and the Juvenile Diabetes Foundation International in New York City. It gives tips for preparing for appointments with the physician and lists guidelines for patients to follow, including:
· Understand that diabetes is a lifelong condition.
· Keep blood glucose levels as close to normal as possible.
· If you smoke, make a serious effort to quit now.
· Check your feet every day for early signs of ulcers, infection, changes in color or temperature or abnormal toenails.
· See your doctor regularly.
· Get a dietitian's help with meal planning.
The yearlong pilot program is running through June, and outcomes such as hospitalizations, emergency room visits, lab results, and amputations are being measured. Focus groups will be held with patients and providers to get feedback, and after changes are made, the program could be ready to implement in other plans within six months, Barta says. Preliminary findings from another study Prudential performed with its Jacksonville, FL, plan showed that a nurse case manager model was successful in helping patients improve weight, total cholesterol, and blood sugar control. That idea, in which a nurse kept regular contact with patients, could be incorporated into the overall diabetes program.
Barta says diabetes is a priority for Prudential, even though some health plans have shied away from comprehensive diabetes management because it's expensive, and the gains tend to be long-term. "It's the right thing to do," she says. "I think it's very well-documented that usual care for patients with diabetes leaves much to be desired. So if we all attack this in a similar way - because how different could our guidelines be from anyone else's - as people transfer among a variety of managed care organizations, we all stand to benefit from whatever other company started the work."
[For more information on diabetes management, contact Patricia Barta, MPH, RN, CDE, manager, health management programs, Prudential Insurance Company of America, 56 Livingston Ave., Roseland, NJ 07068. Telephone: (973) 716-5886.]
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