Telephone Management Research Articles

Managing the Space between Visits: A Randomized Trial of Disease Management for Diabetes in a Community Health Center

Diabetes outcomes are worse for underserved patients from certain ethnic/racial minority populations. Telephonic disease management is a cost-effective strategy to deliver self-management services and possibly improve diabetes outcomes for such patients. We conducted a trial to test the effectiveness of a supplemental telephonic disease management program compared to usual care alone for patients with diabetes cared for in a community health center. Randomized controlled trial. All patients had type 2 diabetes, and the majority was Hispanic or African American. Most were urban-dwelling with low socioeconomic status, and nearly all had Medicaid or were uninsured. Clinical measures included glycemic control, blood pressure, lipid levels, and body mass index. Validated surveys were used to measure dietary habits and physical activity. A total of 146 patients were randomized to the intervention and 149 to the control group. Depressive symptoms were highly prevalent in both groups. Using an intention to treat analysis, there were no significant differences in the primary outcome (HbA1c) between the intervention and control groups at 12 months. There were also no significant differences for secondary clinical or behavioral outcome measures including BMI, systolic or diastolic blood pressure, LDL cholesterol, smoking, or intake of fruits and vegetables, or physical activity. A clinic-based telephonic disease management support for underserved patients with diabetes did not improve clinical or behavioral outcomes at 1 year as compared to patients receiving usual care alone.

The structure and content of telephonic scripts found useful in a Medicaid Chronic Disease Management Program

In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease Management Program (ICDMP), a programme intended to improve the health and healthcare utilization of 15,000 Aged, Blind and Disabled Medicaid members living with diabetes and/or congestive heart failure in Indiana. Within ICDMP, programme components derived from the Chronic Care Model and education based on an integrated theoretical framework were utilized to create a telephonic care management intervention that was delivered by trained, non-clinical Care Managers (CMs) working under the supervision of a Registered Nurse. CMs utilized computer-assisted health education scripts to address clinically important topics, including medication adherence, diet, exercise and prevention of disease-specific complications. Employing reflective listening techniques, barriers to optimal self-management were assessed and members were encouraged to engage in health-improving actions. ICDMP evaluation results suggest that this low-intensity telephonic intervention shifted utilization and lowered costs. We discuss this patient-centred method for motivating behaviour change, the theoretical constructs underlying the scripts and the branched-logic format that makes them suitable to use as a computer-based application. Our aim is to share these public-domain materials with other programmes.

T1034 Observing Hand-Offs and Telephone Management in GI Fellowship Training

T1034 Observing Hand-Offs and Telephone Management in GI Fellowship Training

C-A2-04: The Geisinger Transitions of Care Initiative: Overview of an Interdisciplinary Quality Improvement Process

John B Bulger, DO, Kenric A Maynor, MD and Seth Frazier, MBA John B Bulger, DO, Geisinger Health System; Kenric A Maynor, MD, Geisinger Health System; Seth Frazier, MBA, Geisinger Health System

Working Toward Wellness: Telephone Care Management for Medicaid Recipients with Depression, Thirty-Six Months after Random Assignment

Although low-income individuals are disproportionately likely to suffer from depression, few receive treatment, and even fewer persist with their treatment. Randomized controlled trials have demonstrated that telephone care management interventions can successfully encourage primary care patients and employed workers to talk with mental health specialists, increase their use of antidepressants, reduce their depression, and even improve their work performance and job retention. This report presents the 36-month results from a program called “Working toward Wellness” (WtW) that provided telephone care management to a low-income population — depressed parents receiving Medicaid in Rhode Island — to encourage them to seek treatment from a mental health professional. The project was conducted as one of four studies in the Enhanced Services for the Hard-to-Employ Demonstration and Evaluation Project, which was sponsored by the Administration for Children and Families and the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services (HHS), with additional funding from the Department of Labor. WtW is being evaluated by MDRC in partnership with United Behavioral Health (UBH) and Group Health Cooperative (GHC). UBH delivered the care management services, and GHC designed the intervention and provided technical assistance and training to UBH staff. This report presents the following key findings: - WtW care managers used the telephone effectively to initiate engagement with people with depression to consider treatment. - WtW increased the use of mental health services while the intervention was running, but it did not help individuals sustain treatment after the intervention ended. - Authorization procedures limited the capacity of WtW care managers to function as liaisons between clients and clinicians; care managers could not provide direct feedback to the clinicians regarding WtW clients as they progressed in treatment. - WtW did not have an effect on depression or employment outcomes at 36 months after the end of the intervention.

Consensus Statements: Ambulatory Pediatric Oncology Nursing Practice

The pre-conference workshop at the 32nd Annual Conference of the Association of Pediatric Hematology/Oncology Nursing, held in September 2008, focused on issues faced by pediatric oncology nurses in the ambulatory setting. The workshop was developed after several years of intense discussions at several forums. Therefore the need for an extended discussion period with ambulatory pediatric oncology nurses across the country to address these concerns was evident. There has been a major shift over the past ten years from inpatient to outpatient treatment in oncology (Chabot & Fox, 2005). This shift has resulted in numerous unique challenges for the pediatric oncology nurse. Challenges include lack of staffing resources for fluctuating patient volume and acuity, telephone triage volume and management, home care patient issues, scheduling systems, patient flow and wait time, and multi-institutional communication. This article reports the results of the APHON workshop which utilized the evidence from adult ambulatory oncology literature and standards and the recommendations of the expert pediatric oncology nurse participants to develop global statements about pediatric oncology ambulatory practice standards. The energy and productivity of the group was evidence of a common theme and demand for attention to the ambulatory nursing staff and practice. The ability to identify common threads and reach consensus with powerful statements of practice supports the continued use of such forums to move practice forward.

The Use of Telephonic Case Management to Link a Special-Needs Population with a Primary Care Physician

Gold Choice, a Medicaid managed care organization for individuals with mental health and/or substance abuse diagnoses, uses telephonic case management to link members with primary care providers (PCPs). This study assessed the effectiveness of this approach. The number of new members without a PCP at baseline were compared with primary care encounter data documenting first PCP visits from 2003 to 2006. Paired t tests compared the mean number of new Gold Choice members linked to primary care who received telephonic case management. During the 4 years, 52% of new members without a PCP at baseline were linked to a provider within 12 months. Paired sample t tests comparing the mean number of members linked to a PCP from baseline to 12 months for each of the 4 years yielded statistically significant results. More than 50% of members who indicated at baseline that they had not seen a PCP were linked to primary care during the first 12 months of their enrollment in Gold Choice, suggesting that that telephonic case management may be an effective approach to linking mentally ill and/or chemically dependent patients to primary care.

Experiments in Coordinated Elder Care

Experiments in Coordinated Elder Care

Diabetes Disease Management Results in Hispanic Medicaid Patients

To investigate outcomes of a telephonic nursing disease management program for Medicaid patients with diabetes residing in Puerto Rico. A 12-month, matched-cohort study. Four hundred and ninety (490) intervention group members matched to 490 controls. Disease management diabetes program. For those in the intervention group, the disease management program customized a self-management intervention plan. Medical service utilization, including hospitalizations, emergency department visits, physician evaluation and management visits, selected clinical indicators, and financial impact. The intervention group showed significant effects compared with the control group, including a 48% reduction in inpatient bed days, and a 23% increase in ACE inhibitor use, resulting in a return on investment estimate of 3.8:1. The study demonstrates that a nursing disease management program for diabetes can significantly improve hospitalizations, drug compliance, and vaccinations in a Hispanic Medicaid population.

An evaluation of educational outreach to improve evidence‐based prescribing in Medicaid: a cautionary tale

Evidence suggests that educational outreach ('academic detailing') improves evidence-based prescribing. We evaluated the impact of an academic detailing programme intended to increase new statin prescriptions. In a 2 x 2 factorial design we evaluated the effect of an academic detailing programme with/without telephonic care management for patients. Eligible patients were continuously enrolled Medicaid members at high risk for cardiovascular disease utilization who were not receiving statin medication in the 18 months prior to the intervention. All primary care prescribers assigned to these patients were randomized by clinic to academic detailing. Two trained nurses provided the detailing to prescribers, including specific discussion about the use of statins in this high-risk patient population. Nurses left the prescribers with a summary of clinical practice guidelines, a one-page detailing sheet and a list of patients under the care of the prescriber who were candidates for statins. The primary outcome was the incidence of a new statin prescription claim during the 6-month intervention period and the subsequent 6 months. Logistic regression models were used to estimate main effects of the interventions and to adjust for potential confounding variables in the study. Forty-eight clinics were randomized, effectively randomizing a total of 284 patients and 128 prescribers. Among the 284 patients, 46 (16%) received a new statin claim during the evaluation period. Controlling for significant bivariate associations, the academic detailing intervention had no significant effect on new statin prescriptions compared with the control group (odds ratio = 0.8, 95% confidence interval: 0.4-1.6, P = 0.5). Among this Medicaid population at high risk for cardiovascular events, an academic detailing programme to increase statin prescriptions was not effective. To assist others to learn from our failed effort, we identify and discuss critical elements in the design and implementation of the programme that could account for these results.

Impact of Disease Management on Utilization and Adherence With Drugs and Tests

OBJECTIVE—The purpose of this study was to evaluate the effect of telephonic care management within a diabetes disease management program on adherence to treatment with hypoglycemic agents, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), statins, and recommended laboratory tests in a Medicaid population.RESEARCH DESIGN AND METHODS—A total of 2,598 patients with diabetes enrolled for at least 2 years in Florida: A Healthy State (FAHS), a large Medicaid disease management program, who received individualized telephonic care management were selected if they were eligible for at least 12 months before and 12 months after beginning care management. Patients were matched one-to-one on all baseline characteristics to 2,598 control patients. The impact of care management on utilization and adherence rates for diabetes-related medications and tests was analyzed with the difference-in-difference estimator.RESULTS—Changes in utilization were evaluated separately for those who were characterized as adherent to treatment at baseline (“users”) and those who were not (“nonusers”). Both groups achieved significant improvement in adherence between baseline and follow-up. Nonusers increased their overall hypoglycemic use by 0.7 script (P < 0.001), by 0.7 script for ACEIs and statins (both P < 0.001), by 0.8 test for A1C (P < 0.001), and by 0.7 test for lipids (P < 0.001). Users increased hypoglycemic use by 1.5 scripts (P < 0.001) and insulin use by 0.9 script (P < 0.001).CONCLUSIONS—The FAHS telephonic care management intervention effectively induced Medicaid patients with diabetes to begin treatment and improved adherence to oral hypoglycemic agents and recommended tests. It also substantially improved adherence among baseline insulin users.

Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial.

Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective. To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers. A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded. A telephonic outreach and care management program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy. Depression severity (Quick Inventory of Depressive Symptomatology, QIDS) and work performance (World Health Organization Health and Productivity Questionnaire [HPQ], a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents). Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (beta=2.0; P=.02; equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed. A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers. clinicaltrials.gov Identifier: NCT00057590.

Building the Foundation of a Better Healthcare System: for the Common Good

Has a fellow traveler on an airplane ever asked you what it is you do? When someone asks me the “What do you do?” question, I tell them, “I’m building the foundation of a better healthcare system.” I believe it is the destiny of family medicine to be the foundation of a new system of healthcare for the common good of the American people. I believe that our discipline was created for this moment in time when all the interested parties in the business of healthcare are looking out for their own self-interests and not the common good. As natural servant leaders, family physicians work close enough to the people to care and work for the common good. As the trainers of the next generation of family physicians, we are building the foundation of a better health care system. I envision a system of healthcare with a medical home for all Americans. These medical homes will be created, sustained, and staffed by family physicians and our primary care colleagues. The American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association have published an excellent description of the medical home entitled “Joint Principles of the Patient-Centered Medical Home.”1 I encourage you to read these joint principles as you build the medical homes in your practice. When you build a good medical home you are building the foundation of a better health care system. The Commonwealth Fund 2006 Health Care Quality Survey provides new evidence of the value of medical homes.2 Promising findings from this survey are that adults who have a medical home have improved access to care, higher rates of preventive screening, are better prepared to self-manage their hypertension, and racial disparities in access to and quality of care are reduced or eliminated.2 I believe that the medical home is the unit of primary care for this country, and that we are approaching the tipping point in the rest of the country coming to the same conclusion. What are the training implications of this? Our family medicine centers must be medical homes that truly offer an apprenticeship experience to learners at all stages from premedical students, to medical students, to residents, to fellows, to faculty. We must ensure that our residencies train our residents so that they will thrive in the medical homes of the future. Is it time for all medical students to receive training in a medical home, so they understand the foundation upon which the health care system will be built? Is it time to require a continuity of care experience in a medical home as a core competency to graduate from medical school? One problem with the medical home model is that you can’t fund it on E and M codes alone. It requires additional reimbursement that pays for care coordination and management that occurs outside of the office visit. Who deserves extra reimbursement as a medical home? There is an opportunity for practices to become certified as medical homes by the National Committee for Quality Assurance (NCQA) with their Physician Practice Connections program. I predict that in the near future this certification will enable medical homes to receive enhanced practice revenue. This revenue will allow us to continue the work that we do every day that just isn’t paid by office visits, such as telephone management, case and disease management, electronic medical record costs, and continuous quality improvement to name a few. A number of pilot programs are underway linking the Physician Practice Connections certification with enhanced revenue. If you review the Physician Practice Connections Standards of the NCQA (Table 1 ▶) most family medicine teaching practices have already put many of the requirements into place. Table 1. NCQA Practice Connection Standards We are a patient-care based specialty and our training needs to maintain that emphasis. Our job is to train our residents as the clinical equivalent of pleuri-potential stem cells. After residency, family physicians can differentiate into whatever their position or community requires. But, at the core, they were trained in the basic principles of family medicine in a medical home. I believe it is the destiny of family medicine to be the foundation of a better healthcare system for America. We are needed … for the common good.

Application of an Outcome-Directed Behavioral Modification Model for Obesity on a Telephonic/Web-Based Platform

This study assessed intervention results from 205 individuals enrolled in a telephonic weight management program. Average weight of enrolled participants was 270 pounds with an average body mass index (BMI) of 44. The study was an initial program assessment of multiple outcome areas including weight loss, behavior change, global distress, and productivity. The study used pre and post client self-reported information to assess these areas. The average participant in the program lost 8 pounds, or 3% of intake weight, which represents a strong trend toward expected results (p = .08 one-tailed t-test). Other encouraging results include significant improvement in distress, improvement in absenteeism and presenteeism, as well as increases in healthy behaviors such as nutrition and exercise plans. This article will highlight an online outcomes management system that enables the program participant and service provider to assess appropriate level of care, effectiveness of services, and likelihood of success. This ongoing assessment allows continual customization of the plan of care in order to maximize outcomes. The study demonstrates the impact of obesity on behavioral health and productivity, and provides evidence that telephonic interventions delivered in tandem by behavioral health specialists and registered dieticians can yield effective results. Because these results are preliminary, recommendations are also provided for program enhancement.

Health Services Outcomes for a Diabetes Disease Management Program for the Elderly

Our objective was to investigate the utilization, drug, and clinical outcomes of a telephonic nursing disease management (DM) program for elderly patients with diabetes. We employed a 24-month, matched-cohort study employing propensity score matching. The setting involved Medicare + Choice recipients residing in Ohio, Kentucky, and Indiana. There were 610 intervention group members over the age of 65 matched to a control group of members over the age of 65. The DM diabetes program employed a structured, evidence-based, telephonic nursing intervention designed to provide patient education, counseling, and monitoring services. Measurements consisted of Medical service utilization, including hospitalizations, emergency department visits, physician evaluation and management visits, skilled nursing facility days, drug utilization, and selected clinical indicators. Among the results, the intervention group had considerably and significantly lower rates of acute service utilization compared to the control group, including a 17.5% reduction in hospitalizations, 22.4% reduction in bed days, 12.3% increase in physician evaluation and management visits, 23.7% increase in angiotensin-converting enzyme (ACE) inhibitor use, 13.3% increase in blood glucose regulator use, 11.8% increase in hemoglobin A1c (HbA1c) tests, 10.3% increase in lipid panels, 26.0% increase in eye exams, and 35.5% increase in microalbumin tests. In conclusion, the study demonstrates that a commercially delivered diabetes DM program significantly reduces hospitalizations and bed-days while increasing the use of ACE inhibitors and blood glucose regulators along with selected clinical procedures such as HbA1c tests, lipid panels, eye exams, and microalbumin tests.

Advanced Practice Nurse‐Directed Telephone Management of Acute Pain Following Pediatric Spinal Fusion Surgery

Children undergoing spinal fusion surgery require sophisticated pain management. This study describes an integrated system of pain management primarily directed by an advanced practice nurse (APN), encompassing both the inpatient and outpatient settings. A retrospective chart review was conducted. Pain management and patient education began in the hospital. The APN provided telephone-based follow-up and management after discharge. An average of four phone calls over 9 days was required per patient. No complications were reported. Results of this study support the APN telephone management of postoperative pain once children are discharged following extensive surgery.

Telephone management: a reimbursable expense?

Telephone management: a reimbursable expense?

A Special Issue: Coding for Children With Special Health Care Needs

A Special Issue: Coding for Children With Special Health Care Needs

Alternative Models for Telephone Response to Pediatric Poisonings

Background. Poison Control Centers (PCCs) provide telephone consultations to manage poisonings. They are threatened with funding loss. Policy decision-makers have requested an evaluation of alternate models for telephone management of poisonings. Objective. We examined the feasibility of alternative models for the telephone management of poisonings from the public. Methods. Alternative models evaluated included emergency medical dispatchers (EMDs), advice nurses (RNs), andpoison information providers (PIPs) to manage real andhypothetical poisonings with protocols or computerized references (Poisindex®) with andwithout PCC backup. Results. EMDs andRNs with a structured protocol andaccess to a PCC specialist were able to manage a small subset of poisoning calls. EMDs andRNs managed 6% and12% of poisoning calls respectively. Non-protocol management of hypothetical cases using Poisindex® resulted in mismanagement of cases andlonger periods of time to manage cases. PIPs within a PCC were able to manage a substantially greater proportion of calls, but had a significant portion of non-productive time waiting for a PCC call. Conclusion. EMDs, RNs, andtechnician-level PIPs can manage a subset of poisoning cases using structured protocols. Alternative providers were dependent on PCC staff for consultation of the majority of poisoning calls. There are several obstacles to these models andtheir cost-effectiveness needs to be determined. These studies were the basis of a new staffing model with the integration of PIPs into the call response system in California.

Reduced mortality: the unexpected impact of a telephone-based care management intervention for older adults in managed care.

This analysis evaluated mortality over 24 months for Medicare managed care members who participated in the Care Advocate Program (CA Program) designed to link those with high health care utilization to home- and community-based services. Secondary data from the CA Program, part of the California HealthCare Foundation's Elders in Managed Care Initiative. Randomized-control trial in which participants (N=781) were randomly assigned to intent-to-treat (ITT) and control groups. ITT group received telephonic social care management and 12 months of follow-up. Various multivariate analyses were used to evaluate mortality risk throughout multiple study periods controlling for sociodemographic characteristics, health status, and health care utilization. Older adults (65+) enrolled in a Medicare managed care plan who had high health care utilization in the previous year. ITT group had a significantly lower odds of mortality throughout the study (OR=0.55; p=.005) and during the care management intervention (OR=0.45; p=.006), whereas differential risk in the postintervention period was not statistically significant. Other significant predictors of mortality were age, gender, three chronic conditions (cancer, heart disease, and kidney disease), and emergency room utilization. Findings suggest that the care advocate model of social care management affected mortality while the program was in progress, but not after completion of the intervention phase. Key model elements accounted for the findings, which include individualized targeting, assessment, and monitoring; consumer choice, control, and participant self-management; and bridging medical and social service delivery systems through direct linkages and communication.