Care managers often play a central role in the treatment plan for patients who have complex chronic illnesses. While their services – usually over the telephone – are critical, they vary in their effectiveness due to the challenges busy care managers face in structuring patient interactions and providing sufficient follow-up.
Expanding the reach of telephone care managers from the clinic to the home can:
- Improve treatment continuity
- Identify problems in early, reversible stages
- Increase the effectiveness of clinician-patient communication
Service Innovation: Telephone Care Management Model
QUICCC investigators have developed a telephone care management model for patients who have both diabetes and depression.
Drawing on U-M’s extensive experience with depression management and physical activity promotion, this new service includes detailed week-by-week workbooks for both care managers and patients that can be used to:
- Monitor patients’ progress toward knowledge attainment and behavioral goals
- Promote increased physical activity using pedometers for feedback on activity levels
- Address patients’ needs for depression and diabetes care management
Ongoing research and development
With funding from the National Institutes of Health, QUICCC investigators are conducting a randomized trial of telephone care management for patients with diabetes and depression. More than 300 patients are being recruited from UMHS, VA Ann Arbor Healthcare System (VAAAHS) and Genesys Health System in Flint. Patients are randomized to:
- Brief education about depression, diabetes self-care, and physical activity; or
- Telephone care management including antidepressant medication care management and/or cognitive behavioral therapy (CBT).
Outcomes are being measured at 12 months post enrollment and include patients’ glycemic control, depressive symptoms, activity levels and self-management behaviors.
Caring for patients with complex chronic diseases is extremely challenging, and community practices typically do not have required information resources or organizational systems in place to be successful. Inadequate disease management of chronically-ill patients can result in costly, preventable declines in health and increased healthcare utilization.
Developing tools for proactively monitoring chronically-ill patients in busy primary care settings is a widely recognized goal.
For-profit efforts to develop patient monitoring systems have resulted in little success, producing systems that are cost-prohibitive, limited in their flexibility, and unable to meet the needs of patients with a range of social situations. Moreover, these systems typically introduce huge quantities of unfiltered information into the clinical setting, most of which is rarely used.
QUICCC is developing a suite of patient monitoring and behavior change resources that rely mainly on currently available communication tools such as interactive voice response calls and web-based monitoring strategies. The goal is to produce tools that will be low cost, flexible, and functional without specialized hardware in the homr or information technology expertise in small community practices.
In collaboration with community clinicians, algorithms will be created for automated assessments that address the needs of patients with chronic illness. Based on practices’ recommendations, a system-redesign to respond to patient assessment reports will be developed.
Clinicians will be able to select:
- Patients to be monitored
- Preferred feedback mechanism
Patients will be able to:
- Select their preferred method for entering self-monitoring data
- Receive immediate feedback during automated assessments
- Obtain more detailed, tailored follow-up based on their assessment reports
Priorities driving service development include:
- Averting adverse outcomes
- Avoiding staff burden
- Enhancing patient-provider communication
- Improving patient-centered care
Ongoing research and development
In collaboration with Blue Cross Blue Shield of Michigan, experts in chronic illness care and primary care practices across the state, QUICCC investigators are developing a portfolio of user-friendly informatics tools for health and health behehavior monitoring of patients with diabetes, heart failure and/or depression. Qualitative data from both patients and clinicians will be used to develop and implement prototypes within primary care settings - both academic and community-based. Subsequent work will evaluate the impact of the monitoring tools on outcomes and costs.