Changing the Paradigm from Treatment to
Prevention: A Diabetes Case Model
Alycia S. Sepe, RN, BSN
National Clinical Director, Sales
Health Management Corporation
Marketplace Dynamics
Increased “consumerism”
 Increased individual control and incentive (economic skin in the game):
CDHPs and HSAs
 Vital need for personalized information and decision support:
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What is appropriate care?
How to reduce out of pocket costs?
How to achieve those potential savings?
Increased impact on employers
 Medical costs increasing dramatically
 Deteriorating employee health impact on productivity
Increased provider accountability
 Public reporting on cost and quality
 “Pay for performance” and “tiering”
Increased use of technology
 Essential to enhance quality and improve efficiency
 Evidence-based care processes, supported by automated clinical
information and decision support systems
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HMC Offers Life2
A solution for the total population
HMC has built a strategy to help
employers and health plans manage their
TOTAL POPULATION
Members in
Need of Targeted
Care Management
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…and everyone
moving in between…
Members in
“Peak”
Condition
Health Management
Continuum
Well
Well-Being
Chronic
Conditions
At Risk
Catastrophic
Conditions
Nurse Line Demand Management - (e.g., acute conditions, self-diagnosed conditions, strains, sprains, colds)
Guide - (e.g., navigational and clinical advocacy)
Signals - (e.g., Personal Care Notes & Provider Notifications)
Health
Promotion
Health Risk
Management
At Risk
Conditions
Chronic
Disease Mgmt
Biometric
Screenings
Vitals HRA
Maternity
Onsite Campaigns
Lifestyle
Management Tools
Asthma: Pediatric
and Adult/COPD
Vascular
Online Tools via
Health Portal
Health Coaching:
Online/Telephonic
Cancer
Marketing Support
Wellness &
Newsletter Mailings
Musculoskeletal
Coronary: CAD/HF
High Cost Case
Management
Complex Case
Management
Chronic
Kidney/End-Stage
Renal Disease
NICU
Diabetes:
Pediatric and Adult
End of Life
Integration of Services, Incentives, Communications, Measurement and Evaluation
Disability Management available through WellPoint
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The Peak2 Population
Peak2 is about regular people staying fit by
making healthy lifestyle choices every day
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%
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of people make healthy
decisions about things like diet
and exercise a daily habit
Programs like Balance,
WorkWell, and CareNet
make it easy for the rest
of us to move to Peak
condition
The Move2 Population
Move2 is about helping people live healthier and
avoid slipping toward an avoidable condition
From nutrition to weight loss to stress
management and fitness, we offer programs,
tools and resources that help everyone build
healthier lives
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The Care2 Population
Care2 offers programs that help people with
conditions live as healthy as possible every day
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Asthma
CAD
COPD
Diabetes
Heart Failure
Kidney Disease
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Low Back Pain
Musculoskeletal
NICU
Cancer
Vascular At-risk
Complex Conditions
Staffing:
The Right People
Multi-disciplinary team provides experts in
areas critical to condition management
Pharmacists addressing medication
adherence
Dietitians supporting nutrition
recommendations
Exercise Physiologists supporting
physical activity guidance
Better adherence to
recommendations
means better
managed chronic
conditions
TEAM MEMBERS
Physicians | Pharmacists | Certified Diabetic Educators | Registered Dieticians
Behavioral Health Nurses | Respiratory Therapists | Social Workers
Exercise Physiologists | Health Educators | Certified Case Managers
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Care2 Programs
Care2 programs help people with conditions live
as healthy as possible every day
Dynamic management process,
personalized by member need
Holistic approach allows for program
integration within Life2
Single, fully integrated care
management model
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Care2 Program Goals
Help patients adhere to physician plan of care
Improve adherence to evidence based guidelines
Facilitate better decision making at the consumer
level (consumer responsibility)
Improve quality of life; decrease cost
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Diabetes:
Program Overview
The diabetes program provides support for
participants with Type 1 and Type 2
diabetes to help them take more control of
their health and feel better
• Educates members about living well with diabetes
• Encourages positive behaviors such as diet and medication
adherence
• Reinforces effective self-management strategies
• Reduces complications associated with diabetes
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Life2 Process
IDENTIFICATION
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Data Warehouse
High
Risk
Moderate
Risk
Predictive Modeling
Medical
Lab
Pharmacy
Referrals
HRA
TOTAL POPULATION
MANAGEMENT
Low
Risk
ENGAGEMENT
MEASUREMENT
Member Engagement
• % eligible
participating
Clinical Outcomes
• % adhering to
plan/guidelines
Service Metrics
Healthy
• Member
satisfaction survey
Financial Returns
• ROI
• Cost management
Life2 Diabetes Program:
Member Engagement and
Education
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Condition Management:
Clinical Adherence
Our DM programs
have a dramatic
impact on claims
reduction and clinical
adherence
Members are much
more likely to get the
tests and take the
medications they
need to be healthy
and reduce future
medical claims
n = 275K Total members; 12K members participating in condition management
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All results are from a recent, three-year, internal analysis of our diabetes, CAD, and HF programs for two large clients. For
clients included in the study, service delivery began in September 2002. Asthma and COPD were added in September 2007.
Condition Management:
Productivity Outcomes
Our condition
management
programs result in
increased
productivity, with
members report a 50%
decrease in missed
days of work due to
their condition
n = 275K Total members; 12K members participating in condition management
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All results are from a recent, three-year, internal analysis of our diabetes, CAD, and HF programs for two large clients. For
clients included in the study, service delivery began in September 2002. Asthma and COPD were added in September 2007.
Condition Management:
Clinical Outcomes
Our condition
management
programs help
members achieve
more positive medical
outcomes − The
healthier they are,
the less likely they’ll
be to incur future
medical claims
n = 275K Total members; 12K members participating in condition management
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All results are from a recent, three-year, internal analysis of our diabetes, CAD, and HF programs for two large clients. For
clients included in the study, service delivery began in September 2002. Asthma and COPD were added in September 2007.
Condition Management:
The ROI
Our Life2 condition
management
programs result in
significant ROI
n = 275K Total members; 12K members participating in condition management
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All results are from a recent, three-year, internal analysis of our diabetes, CAD, and HF programs for two large clients. For
clients included in the study, service delivery began in September 2002. Asthma and COPD were added in September 2007.
Condition Management:
Satisfaction
n = 2043
Of the Life2 Condition
Management program
participants:
92% of high-intensity DM
program participants rated
the program nurses as
excellent or very good
95% of high-intensity DM
program participants would
recommend the program
86% of high-intensity DM
program participants rated
the program as excellent or
very good
N=2043
All results are from 2007 internal satisfaction studies
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Challenges
Predictive modeling is not 100% accurate
Difficulty connecting with providers and
community resources
Nurse outreach is limited to those that are
moderate or high risk
Interventions are for those already
diagnosed with diabetes
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HMC Product Enhancement
Diabetes – Alternative Media Pilot
 dLife is the only integrated consumer/patient education and marketing
platform engaging members in the diabetes community
» Video
» Website
» Audio clips
» E-newsletters
» Weekly TV spots
 Piloting education and management assets of dLife in diabetes program to
increase engagement and adherence in 2008
 Pilot will include examination of effectiveness by assessing anticipated
changes in participant knowledge and behavior as well as claims-based
intermediate measures
Disparities – Focus on Appropriate Engagement
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