Diabetes Patient Engagement

Project Goals

The overall goals are to improve care, health, and cost of care for patients with diabetes or congestive heart failure by implementing patient engagement interventions including complex patient management, remote management, and collaborative care for patients with depression. Triple Aim improvement targets include:

Improve care: >50% eligible patients identified for patient engagement interventions and >50% of referred patients participate in intervention (adhere to model)
Improve health: Improve patient-reported health status measures (as measured by
percent of patients at blood pressure goal, LDL goal, and Hba1c goal) for patients who meet target population criteria; reduce Emergency Department (ED) visit rates and hospitalizations by 10% (aggregate relative rate across all pilots)
Reduce cost: Reduce episode costs resulting in 5% total cost reduction (from baseline total bundled costs); reduce hospitalizations by 10% (aggregate relative rate) and reduce aggregate cost of annual episodes by 2%


Diabetes affects more than a quarter of all US residents 65 and older, and is associated with an estimated cost of $174 billion dollars per year.1 Approximately half of adults with diabetes and nearly 60% of elderly adults with diabetes have at least one comorbid chronic
condition.2,3 Approximately 40 percent of adults with diabetes have four or more co-morbid diseases.4 These Medicare beneficiaries account for a disproportionately large share of total Medicare spending.5

To address these serious issues, members were asked to submit patient engagement interventions that had been successfully implemented and shown to improve value-based metrics locally. Twelve intervention proposals were submitted and the Core Team reviewed, prioritized, and in some cases, merged three pilot interventions
to be implemented at co-lead member sites.

Patient Engagement Interventions

The goal of these pilot interventions is to learn how these three interventions—each of which has shown promise for improving quality and decreasing costs for patients with diabetes at some HVHC member institutions— can be successfully implemented at other member institutions. The simultaneous launch of these pilots will allow for comparative analysis of the marginal benefit in patient care and cost effectiveness of the

  • Complex Patient Management: Care coordination has been promoted as an important strategy for achieving the triple aims of improved quality, improved patient experience, and reduced costs, especially for patients with chronic diseases such as diabetes.6,7 The Agency for Healthcare Research and Quality has defined care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.”8 Early care coordination interventions have used heterogeneous approaches9-17 and achieved limited success among patients with diabetes.18-20 More recent care coordination interventions have used more refined approaches and have been increasingly successful. In 2002 the Center for Medicare and Medicaid Services launched its’ “Medicare Coordinated Care Demonstration (MCCD)” at 15 sites. Although early analyses failed to show consistent benefit21, follow up studies have identified key features for success and have demonstrated both improved quality and decreased cost.22 These programs targeted the highest risk patients and shared 5 key features: face-to-face contact (rather than exclusively phone contact), engagement with patients’ physicians, use of patient education and behavioral change techniques, management of care transitions, and assiduous medication management.23,24
  • Remote Patient Management: Telemedicine is another strategy that has been used to address gaps in care, and several large studies have demonstrated that chronic disease management delivered via the phone is effective at lowering disease markers such as hemoglobin A1C and LDL levels.6-11 These programs have been found to be especially effective among older and underserved patients.12-14 However, evidence that telephone management of patients with diabetes can reduce cost and utilization has been sparse.15-17 Several recent studies suggest that case management programs that are exclusively phone-based may be less effective than those that incorporate in-person encounters.18-20 The relative cost-benefit ratio of the two types of programs is not known.
  • Collaborative Care for Diabetics with Depression: Patients with co-morbid diabetes and depression present a unique set of clinical challenges. Depression is common among people with diabetes with an estimated prevalence of 11% for major depressive disorder and 31% for significant depression symptoms.1-3 Patients who have both conditions have been shown to have worse functional status, poorer disease control and higher mortality than their non-depressed counterparts.2,4,5 In addition, co-morbid depression and diabetes is associated with higher healthcare costs. The “collaborative care model” is the most widely accepted strategy for improving outcomes among patients with diabetes and depression. Key features of this model include: a) a multi-professional care team including a primary care physician, mental health professional, and Care Coordinator, b) a structured management plan, c) scheduled patient follow-up, and d) enhanced inter-professional communication.7 Over the past 10 years, definitive evidence that the collaborative care model is a cost-effective approach for improving depression-related outcomes among patients with diabetes has accumulated steadily.7-15. Although early work failed to show improvements in diabetes control, more recent studies that combine the collaborative care model with case management have improved both diabetes and depression-related outcomes while controlling costs.9,11,13,15-18

Standard metrics are being used across all three pilots: proportion of patients with HbA1c, blood pressure, and LDL at target levels; health service utilization, including inpatient, outpatient and emergency department use; as well as the reach of the program (the number of patients eligible for the intervention who actually enroll).These data elements are included in the condition-level data specification that HVHC members submit. The pilot studying collaborative care for diabetic patients with depression is collecting additional elements including the proportion of patients identified with depression who completed a follow-up evaluation within a defined time window and the proportion of patients diagnosed with depression who achieve remission. In addition, all pilot sites will collect patient reported measures (PRM) as part of the intervention. Some institutions will begin collecting these measures with their initial launch of the pilot and others will integrate this component in subsequent stages.