National Exemplary Practice Award 1998 Winners

The National Exemplary Practice Program was initiated in 1996 to encourage the rapid adoption or adaptation of innovative ideas and approaches throughout the managed care industry. "Chronic care" was chosen as the category for this years program, as chronic conditions are the major cause of illness, disability, and death in the United States. The winners of the 1998 AAHP/MHCA National Exemplary Practice Program Awards are Humana, Inc. for their Congestive Heart Failure Disease Management Program and Prudential for their Diabetes Mellitus Program.

Humana, Inc.

Congestive Heart Failure affects an estimated 4.7 million individuals nationally, with 400,000 new cases diagnosed each year. Heart failure prevalence increases significantly with age and the disease is the number one reason for hospital admissions in the Medicare population. In 1995, Humana, Inc. evaluated their utilization data and identified CHF as a high-frequency, high cost condition for their population. They believed that there was potential for improved clinical management and measurable reductions in unnecessary hospitalizations and emergency room visits for this population. Therefore, Humana contracted with a vendor, Cardiac Solutions which is a division of Ralin Medical, to provide automated, on-line disease-management services beginning in March of 1996. Components of the disease management program, MULTIFIT, include patient participation in their care, 24 hour access to a disease manager assigned to each patient, initial interventions consisting of a one and one half hour visit to the home of the patient for physical exams and education about the disease, and ongoing contact with the patient and the patient’s physician to discuss the patient’s status and any changes to the treatment regimen. By design, MULTIFIT allows for individualized care management. Humana’s implementation of this program resulted in the following: a 60% decrease in hospital admissions from the first period of evaluation to the second; inpatient costs dropped 78% from the first to the second period; and functional status, using the Duke Activity Status Index, improved 15% overall. All of these improvements are attributed to the program’s attention not only to heart failure, but to the comorbid conditions, concurrent medications, laboratory abnormalities and symptoms represented by these conditions.

Prudential

Approximately 16 million Americans have diabetes, costing the nation $98 billion annually for care. Each year diabetes causes 12,000 - 14,000 newcases of blindness, 27,900 people to have kidney failure and 56,000 lower-limb amputations. In a 12-month prospective randomized controlled trial, Prudential compared a nurse care management model for diabetes care with usual diabetes management in a primary care setting. This study was designed to detect a changes in hemoglobin A1c among patients treated by two approaches. The American Diabetes Association guidelines recommend that all persons with diabetes attempt to achieve near normalization of blood glucose levels, and detect and treat early, complications and cardiovascular risk factors. However, many of these recommendations are not routinely followed in medical practice. Prudential’s approach to intervention was to place a care manager, a registered nurse who is a certified diabetes educator trained to follow a set of detailed management algorithms, under the direction of a board-certified family medicine physician and endocrinologist. These algorithms assisted the care manager in progressively moving the patient toward improving glycemic control through adjustment in medication, meal planning and exercise reinforcement. Members met with the nurse manager for an initial 45 minute assessment and for instruction on blood glucose monitoring, and again for a follow-up visit two weeks later. Members were also referred to a five week, 12 hour ADA-certified diabetes education program which included individual counseling with a dietitian, an exercise therapist, and group diabetes education classes. At the study’s conclusion, the nurse care management group showed a greater drop in HbA1c (-1.7% vs. -0.6%), had a greater decrease in fasting blood glucose levels (48.3mg/dl vs.14.5 mg/dl), and was two times more likely to have patients report an improved health status. Prudential estimates that if this level of control were to be maintained for all diabetics, the projected lifetime risk of diabetes complications would be reduced by 68 - 85%.

Accepting the awards on behalf of their organization:

Humana, Inc.: Jerry Reeves, MD from Humana & John Cover, from Ralin Medical

Prudential: Chuck Cutler, MD