Coordinating Diabetes Care on a Payer's Behalf

Mary Ellen Wolf, BSN, RN, CDE, has been a diabetes educator for more than 20 years, but in 2014 her role changed: she joined Healthways, which contracts with insurers to bring the patient-centered medical home (PCMH) model into primary care practices.

She’s now a care coordinator, charged with identifying those patients in the health plan who are using care in a fragmented way. Once found, both the patient and the primary care physician (PCP) must be put on a new path of using the right amount of care in the right places. It makes Wolf a foot soldier in the quest to “bend the cost curve” in healthcare spending, which CMS estimates could consume 19.6% of the economy by 2024.

Her talk, “Can Diabetes Educators Be Care Coordinators?” took place on the first day of the annual meeting of the American Association of Diabetes Educators (AADE), which meets through Monday in San Diego, California.

The idea of the Patient Centered Medical Home (PCMH) originated in 1967, but it took years for the delivery model to pick up steam, before it was folded into the Affordable Care Act in 2010. While healthcare costs are driving the shift, PCMH isn’t just about saving money—it’s about bringing more accountability to the system.

Wolf’s basic tasks include working PCPs and nurse practitioners to keep patients out of the hospital or ending up with a cabinet full of medicine they don’t take. Most of the savings from care coordination, she said, come from reduced hospital admissions and fewer visits to the emergency room (ER).

She describes the combination of an aging population and the ACA bringing new wave of patients into primary care as a “perfect storm” to drive new delivery models, PCMH among them. “When this is done correctly, it generally produces a higher quality of care at a lower cost,” she said. And, “It’s a better experience for the patient and the provider.”

Part of the model is meeting patients on their terms, such as being open beyond normal business hours. “Care needs to be accessible. If you have a patient working two jobs, how does he get to the clinic?”

Quality and safety are “huge components” of PCMH, she said. For those with diabetes, the model calls for using care coordinators to help patients and families navigate the web of specialists, medications, and complications that can come with the disease. A patient could avoid a trip to the ER if Wolf sends a nurse to the home for a safety visit, or if she has a medical device delivered.

Her role is aided by the joint statement of January 2015 from AADE, the American Diabetes Association, and the Academy of Nutrition and Dietetics, which found that patients should receive diabetes self-management education (DSME) immediately after diagnosis. The algorithm in the document, she said, not only spells out who should have DSME but also “what should be discussed.”

While her years as a CDE inform her new role, she said, “I fully believe other disciplines can do this job very well,” such as registered dietitians or physical therapists.

Fragmentation of care is a challenge, she said, and emergency rooms that advertise how short the wait is don’t help. It creates the cases she sees—patients with chronic disease who are taking more than a dozen medications, or making multiple visits to urgent care facilities, because they don’t have a primary care physician.

The patients she works with are privately insured—either through their own jobs or a spouse's—and they are “very ill; they have comorbidities.” She finds these patients by looking at claims data, which reveal histories of overusing the emergency room or using multiple specialists. Many have mental health issues but have not received care, because so many providers won’t accept insurance.

In Wolf’s program, patients commit to taking her call once a week. She asks whether they have followed up on referrals, and she tries to get more into DSME. The current level of DSME is “dismal,” she said, with only about 6.8% of those eligible receiving lessons that have been shown to reduce weigh and blood glucose levels.

CDEs make ideal coordinators, she said, because so many have already been doing these tasks for years. She is part teacher, part resource. By design, Wolf lives in the area where she serves patients, so she knows the medical infrastructure, and the social supports.

Throughout, she said, “I document what I’m doing in the (electronic health record) that belongs to the insurance company.”

Decisions are driven by the vast amounts of data insurers keep: If a patient needs a specialist, Wolf can find out which ones are cost-effective. If a provider wants to send a patient for a mammogram, she can find a freestanding center instead of a hospital that will also charge a facility fee. She can work with a pharmacist separately contracted by the payer to review the patient’s prescriptions, to learn not only which ones are truly needed but also which providers are prescribing unnecessary therapies.

Does care coordination work? While it has a cost, Wolf said that her Healthways program is creating results: From 2011 to 2015, care coordination has reduced hospital admissions 13.5% and reduced ER admissions 7.3% per 1000 plan members.

Wolf concluded her talk with some case studies, including a woman who was seeing 9 specialists and had made 200 visits to the ER in the past year, wasn’t using her CPAP for sleep apnea and still had uncontrolled diabetes. When contacted about the woman’s case, the PCP shook the care coordinator’s and said, “Thank God.”

The first task was obvious: “We got her access to mental health services that were sorely needed.”

Care coordination had not only streamlined the woman’s care, but her A1C fell from 13.3% to 8.7%. And, Wolf said, “In a 5-month period, the patient hasn’t been to the ER at all.”