SummaryThe Los Angeles County Department of Health Services implemented disease management programs for uninsured and underinsured, low-income patients with diabetes, asthma, and heart failure who have historically not had access to this type of care and support. The program uses a proactive approach to identify and stratify patients into groups based on their risk profile, with each group receiving services tailored to its needs. The process of care has been restructured to improve coordination of services and to increase efficiency, with more than one-half of patient contacts taking place over the phone or through remote monitoring. The program has reduced missed school days and emergency department and inpatient use for children with asthma and improved glucose, lipid, and blood pressure control for patients with diabetes. Based on these successes, the program will be expanded to include adults with asthma and patients with congestive heart failure, hypertension, and lipid disorders.Moderate: The evidence consists of before-and-after comparisons of key measures of diabetes and asthma care. The program has not yet undergone a rigorous evaluation; therefore, confounding factors cannot be ruled out.
Developing OrganizationsLos Angeles County Department of Health Services
Date First Implemented1998
The department initially began to offer disease management, including expanded access to outpatient services and more integrated care delivery, as part of the Medicaid 1115 Waiver Demonstration project. The program has been refined and enhanced on a continual basis since that time, with programs having been added for new conditions; existing programs having been expanded to additional sites; and the design, staffing, and tools used by current programs having been modified.
Patient PopulationThe program serves residents of Los Angeles County, a 4,000-square-mile area.Vulnerable Populations > Impoverished; Medically uninsured; Urban populations
Problem AddressedMany people with chronic diseases, particularly those who are low-income or uninsured, are treated in an episodic, reactive fashion, resulting in poor ongoing control of their condition(s) and inefficient use of high-cost inpatient and emergency services.
- Poor control: Patients initially entering the Los Angeles County diabetes program had poor blood glucose and lipid control. The average blood glucose as measured by hemoglobin A1c (HbA1c) level was 11.3 percent, well above the target of 7 percent or less. Average levels of "bad cholesterol" (low-density lipoprotein [LDL]) were 121 mg/dL, well above the target of less than 100 mg/dL.
- Inefficient use of high-cost resources: Low-income and uninsured patients with chronic conditions tend to seek care only when they have bothersome symptoms. For example, those patients with hypertension and dyslipidemia often have no symptoms until the preventable complications of these primary risk factors cause a devastating event, such as a heart attack or stroke. The failure to seek care shows up in the statistics for Los Angeles County emergency departments (EDs). In the first 6 months of 2006, the smallest county hospital had 792 ED visits for diabetes, 171 for congestive heart failure (CHF), and 507 for asthma. In 2008, the smallest county hospital had 2,232 ED visits for diabetes, 233 for CHF, and 1,129 for asthma.
Description of the Innovative ActivityThe disease management program consists of an initial assessment of patients to place them into one of three risk categories, along with tailored interventions suitable for each group based on the degree of risk. For all risk groups, the program emphasizes the proactive monitoring and treatment of patients in the outpatient and home care environments to avoid exacerbations that require expensive ED or inpatient visits.
- Initial risk stratification: Patients are stratified into one of three risk groups through a retrospective review that assesses their illness burden (e.g., physiologic variables, laboratory results, functional status) and unscheduled use of rescue-care resources, such as ED visits and hospitalizations.
Low-risk group (estimated population of 20,000 individuals): These individuals tend to have a single, relatively straightforward chronic illness; they feel relatively healthy and rarely seek medical care except in response to specific symptoms. As a result, they do not proactively control their condition. The overall goal with these individuals is to transform episodic, symptom-driven episodes of care into scheduled, nurse-delivered, protocol-driven care.
Medium-risk group (estimated population of 40,000 individuals): These individuals tend to be complex and/or have multiple chronic illnesses with a pattern of high resource use relative to their burden of illness. A typical patient might be a middle-aged diabetic who visits the ED several times a year for treatment of complications related to his or her chronic condition(s). This individual has limited awareness of the importance of managing his or her condition(s) and limited history of regular medication use or keeping regularly scheduled clinic visits. The goal is to transform episodic, symptom-driven episodes of care into scheduled primary care to reduce inappropriate variability and reduce the need for unscheduled rescue care in the hospital or ED.
High-risk group (estimated population of 4,000 individuals): These individuals tend to have multiple chronic illnesses, such as heart failure, diabetes, asthma, and/or chronic obstructive pulmonary disease, along with multiple comorbidities associated with these conditions. They are affected by their diseases on a daily basis and tend to have many scheduled and unscheduled encounters with multiple providers and venues of care. Their medication regimens are confusing, and often one doctor may not know what another is doing with respect to medications, creating frustration for both provider and patient. These individuals usually want to take a more active role in managing their diseases but may not feel capable or knowledgeable enough to do so. The goal is to transform episodic rescue care into scheduled, planned visits with a coordinated, comprehensive care team, thus reducing the need for ED and inpatient care to treat exacerbations.
- Tailored interventions: Each group receives a set of interventions tailored to the level of risk, with an emphasis on proactive outreach via the telephone and face-to-face visits, as outlined below:
Low-risk group interventions: Low-risk individuals receive a membership card assigning them to a medical home that provides protocol-guided, structured care for asthma, diabetes, hypertension, and dyslipidemia, with a focus on the provision of appropriate preventive care. The pediatric asthma program includes a school-based outreach component. Patients also have access to after-hours demand management and same- or next-day scheduled appointments for urgent care.
Medium-risk group interventions: These individuals receive the same services as are provided to the low-risk group, with the addition of a named licensed independent provider as the principal care provider. Select patients are assigned a case manager who is in regular phone contact and can offer same- or next-day appointments for urgent care.
High-risk group interventions: These individuals are interviewed and examined to develop a personalized, comprehensive disease management plan, with an identified, licensed health care professional assigned to function as the care coordinator, key contact, and care delivery provider for most clinical and nonclinical interactions. In addition to traditional face-to-face and periodic telephone encounters, the program includes remote monitoring, education on patient self-management, and integrated clinical decision support systems. The goal is to reduce the number of times that patients with stable chronic disease decompensate, thus averting clinical crises and expensive ED visits and/or inpatient stays. The department is also testing new voice recognition software to gather information from patients to facilitate home monitoring.
Protocols, tools, and other support: Providers use disease-specific protocols developed via collaborative effort to manage ongoing care. Providers attain accuracy, efficiency, and legibility via use of preprinted prescription pads with their identification and contact information, along with formulary approved medications, strengths, doses, routes, and frequencies. An electronic Disease Management Registry was also developed internally to track patient statuses, select labs and other clinical measures, and track current medications through a medication reconciliation module. In addition, there is capability to track expected care manager tasks and identify the patient's medical home.
Context of the InnovationThe Los Angeles County Department of Health Services operates a network of 3 general acute care hospitals, 1 specialized rehabilitation hospital, 2 multiservice ambulatory care centers, 6 comprehensive health centers, 10 personal health centers, and more than 100 private, community-based ambulatory care sites, including school-based sites. The network serves approximately 700,000 unique patients annually, two-thirds (67 percent) of whom do not have health insurance and one-fourth of whom (26 percent) are on Medi-Cal (California's Medicaid program). Among this population, 57 percent are female, whereas 61 percent are Latino, 15 percent are African Americans, 9 percent are white, and 5 percent are Asian. Financially needy Los Angeles County residents can obtain inpatient, outpatient clinic, physician, and certain ancillary services from the department at reduced or no out-of-pocket cost. The outpatient disease management programs were developed primarily as a way to reduce the strain on the county's inpatient facilities. These programs are centrally administered but locally implemented, with the department being responsible for developing tools and vetting clinical content, while local staff run day-to-day operations.
ResultsThe Los Angeles County Department of Health Services' comprehensive disease management programs have resulted in a significant improvement in the ongoing management of diabetes and significant reductions in ED and inpatient visits and missed school days for children with asthma.
Moderate: The evidence consists of before-and-after comparisons of key measures of diabetes and asthma care. The program has not yet undergone a rigorous evaluation; therefore, confounding factors cannot be ruled out.
- Better diabetes control: A review of more than 3,060 patients managed in 5 sites found that average HbA1c levels fell by 2.1 points, average LDL levels fell by 18 mg/dL, and average systolic blood pressure fell by 7 mm Hg.
- Better asthma control, reduced acute episodes: A review of 7,324 patients managed in 93 school-based sites found that more than 90 percent of enrolled patients achieved control of their asthma within 6 visits. ED and inpatient visits fell by more than 70 percent, while missed school days fell by more than 90 percent.
- Use of an automated remote monitoring system: A pilot on 77 heart failure patients showed a combination of lower cost, increased reach, and high concordance with human calls in addition to high patient satisfaction with the system.
Planning and Development ProcessKey steps in the planning and development process are outlined below:
- Assembly of multidisciplinary, disease-specific content experts: In collaboration with physicians, nurses, and nurse practitioners, a team of experts developed the protocols and accompanying documentation tools, patient education materials, and other required resources.
- Pilot testing: After thorough vetting and consensus-building, programs were pilot tested and fine tuned at one site. For example, the pediatric asthma initiative began as an "outreach" program at Los Angeles County-University of Southern California Medical Center in 1997. In 2001, the diabetes program was piloted at the Roybal Comprehensive Health Center, a large, freestanding comprehensive health center site. The advantage of starting small is that the pilots can serve as laboratories to refine the service delivery approach, demonstrate success, and build support.
- Scaling up: The initial pilot programs have been expanded throughout the Los Angeles County Department of Health Services. The pediatric asthma program is now used in more than 90 school-based sites. A CHF program and adult asthma program operate at two sites.
Resources Used and Skills Needed
- Staffing: Each nursing care specialist handles 125 high-risk patients.
- Costs: The estimated cost of each nurse contact is approximately $20. The total annual costs for disease management programs, including care delivered outside of the inpatient setting, are approximately $4 million.
Funding SourcesLos Angeles County Department of Health Services
Funding for current services comes from several sources, including revenues for services provided, Federal grants, State 1115 waivers, and general county tax revenues. Foundation grants support research regarding the disease management programs.
Getting Started with This Innovation
- Involve stakeholders early: Elicit suggestions and respect the input from all persons involved.
- Facilitate communication to forge consensus: Encourage discussions between disease content experts to resolve differing points of view until reasonable consensus can be reached about how the program should be organized and run. When consensus cannot be reached, a ranking executive should make the final decision.
- Make it simple: Design tools that are comprehensive, yet easy and intuitive to use.
Sustaining This Innovation
- Maintain commitment at the top: Ensure that a top-down commitment to the program exists and is maintained, and that leaders recognize and accept the fact that the program will initially increase costs before leading to long-term cost savings from reduced ED and hospital use.
- Remain realistic about finances: Base the business plan on sound finances and realistic timeframes for recouping costs. Be aware that the expenses saved may not accrue to the same organization expending the resources and effort. For example, improving outpatient care may increase outpatient expenditures, yet yield substantial savings in unscheduled ED/urgent care and hospital admissions.
- Recognize that the program is not for the faint of heart: The program requires a radical, paradigm-shifting restructuring of care delivery, with more than 50 percent of services being delivered outside of traditional face-to-face encounters.
- Look far and wide for funding: Many agencies may be interested in funding novel ways to improve care, particularly for underserved and minority communities.
- Hire the right people: Recruit individuals not just for their clinical or financial competence but also for their dedication to the program and its vision.
- Elicit regular feedback and refine as necessary: Persons directly involved in providing care should give regular feedback on the program, so that managers can modify it to address issues and gaps that they identify.
Contact the InnovatorJeffrey Guterman, MD
Chief Research and Innovation Officer
Ambulatory Care Network
Los Angeles County Department of Health Services
14445 Olive View Drive
Sylmar, CA 91342
Innovator DisclosuresDr. Guterman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 01, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.