Should Patients in Population Health Management Programs Have Access to Lay Care Coaches?

Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes. 

That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
 
The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.

Results?

One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

The Disease Management Care Blog's take:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients' language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

Problems to think about for the next study.....

Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, it's another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasn't enough physician buy-in: if there had been higher trust in the care guides' ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

Small Local Program, Big Results: Who Cares If D.C. Is Tied Up in Knots?

While the national mainstream media focuses on Obamacare's dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone First's community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  We're talking hundreds of thousands of dollars in health care costs.

Dr. Schneider's lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonald's, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isn't ready to stop abusing drugs, that doesn't mean he can't be taught to use a glucose meter.  While living circumstances may be chaotic, that doesn't mean she can't use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCB's limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what it's all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

Image from Wikipedia

McKesson Teaches the Disease Management Care Blog About a New Word: Promotores

Over half of the States’ Medicaid programs have myriad disease management programs aimed at the usual illnesses like asthma, diabetes, high risk pregnancy, ASCVD, chronic heart failure, depression and others. Wanting to find out more, the Disease Management Care Blog contacted McKesson’s disease management folks via e-mail and was promptly answered. They have disease management programs in California, Montana, Florida, Illinois, Pennsylvania, New Hampshire, Texas and Oregon.

If you check the National Conference of State Legislatures’ descriptions of the programs as well as the AHRQ ‘how to’ web-site, you’ll note that there is no standard Medicaid template. Once you’ve seen one disease management program, you’ve seen one disease management program. Even with a single disease management company such as McKesson, there is variation. They are fostering assignment of patients to a primary care ‘medical home’ and deploying community based care health workers in Illinois, while in Pennsylvania and Texas, they are deploying a version of pay for performance linked to their programs' recruitment and outcomes.

And speaking of Texas, how about them promotores. Haven't heard of them until you read the DMCB? Well now you know that instead of relying on pricey, remote nurse-based coaching support, it may be appropriate to turn to an alternate care model that depends on lay-health workers who are recruited from the community, are trained and then teach basic self-management skills in the local neighborhood. McKesson, to their credit, picked up on this model also, which was probably an ingredient in securing an extension of their contract. Different States, different Medicaid programs, different approaches.

The DMCB got to meet a real live promotora not too long ago in north Philadelphia and came away seriously impressed. To paraphrase Archimedes, with enough health care workers like her, we can move some serious HbA1c.