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Service Delivery Innovation Profile

Monthly Text Messages Increase Compliance With Recommended Blood Glucose Testing in Medicaid Managed Care Enrollees With Diabetes


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Snapshot

Summary

A Medicaid managed care plan in Delaware uses cell phone text messaging to send members with type 2 diabetes monthly automated educational messages and reminders to make and keep appointments for blood glucose testing. In a pilot study, the percentage of participants receiving timely blood glucose tests rose from 52.3 percent at program inception to 70.5 percent 6 months later. This rate is much higher than the 45.4-percent compliance rate achieved by diabetic members not enrolled in the program. Based on this success, the organization expanded its use of text messaging to other diabetics and pregnant women and new mothers, sending them reminders about the need for prenatal and postnatal care.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation testing rates among diabetic participants, along with comparisons to a control group who were monitored during the testing period.
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Developing Organizations

Delaware Physicians Care Inc.
Newark, DEend do

Use By Other Organizations

  • Based in part on the success of this program, Aetna plans to use the text-messaging model for patient education and appointment reminders for its diabetic and pregnant clients in other Aetna Medicaid managed care programs across the country.
  • Some providers have also adopted this approach. For example, San Mateo Medical Center in California distributed mobile phones with customized software to young asthma patients, allowing them to communicate with and receive real-time feedback from providers on at least a daily basis. The goal is to promote better management of their conditions, thus reducing costly exacerbations. This initiative is described at http://www.innovations.ahrq.gov/content.aspx?id=1690.

Date First Implemented

2006
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Patient Population

The program recruited diabetic teens and adults enrolled in Delaware's Medicaid program. About half of participants are black or Hispanic, half are white, and two-thirds are female.Insurance Status > Medicaidend pp

Problem Addressed

Diabetes is a common, costly condition that can lead to devastating consequences, including death. The incidence and impact of diabetes are particularly high among low-income minority populations, including Medicaid beneficiaries. Regular monitoring of blood glucose levels plays an important role in managing the condition; yet, many low-income individuals with diabetes do not get regular testing.
  • A common, costly, and devastating condition: According to the American Diabetes Association, diabetes affects 8 percent of the U.S. population, or 23.6 million children and adults. Diabetics are twice as likely to have heart disease or a stroke, and they can develop heart disease or have strokes at an earlier age. Women of all ages with diabetes have an increased risk of heart disease. Other complications from diabetes include damage to eyes, kidneys, feet, and nerves. Diabetes was the sixth leading cause of death in 2004 and remains one of the top 10 most expensive medical conditions.1
  • Particularly among low-income minority populations: More than one in seven diabetics in the United States is covered by the Medicaid program, and roughly 16 percent of total Medicaid spending goes to diabetes treatment.1 Blacks, who make up about half of Delaware Physicians Care Inc.'s Medicaid managed care population, are twice as likely to have diabetes as whites. Hispanics, who make up 10 percent of the organization's clientele, have an even higher risk.2
  • Importance of regular monitoring and management of blood glucose: Regular monitoring and management of blood glucose levels (also known as hemoglobin, or HbA1c levels) and other clinical indicators can slow the development of diabetes-related complications according to American Diabetes Association guidelines. According to the American Diabetes Council, every 1 percentage point drop in HbA1c levels (e.g., from 9 to 8 percent) leads to a 35-percent drop in the risk of diabetes-related complications.
  • Failure to receive timely testing: Nearly one out of four individuals with diabetes on Medicaid plans do not get regular testing.3

What They Did

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Description of the Innovative Activity

Delaware Physicians Care, Inc., a Medicaid managed care organization, uses an automatic text messaging program that sends monthly educational messages to members with type 2 diabetes, along with reminders to get their HbA1c levels tested regularly. The program was recently expanded to offer similar services to pregnant women and new mothers, reminding them to seek pre- and postnatal care. Key elements of the program are described below:
  • Identifying members with diabetes: The corporate owner of Delaware Physicians Care, Inc. (Schaller Anderson of Phoenix, AZ) is responsible for identifying members who have diabetes. Disease managers at the corporate office reach out to diabetic members to enroll them into the text messaging program. Primary care providers and/or case managers notify Delaware Physicians Care in cases in which existing members are diagnosed after enrollment.
  • Recruiting members, with efforts based on diabetes severity: Schaller Anderson's disease management staff assesses the severity of the each client's diabetes based on medical reports. The intensity of the organization's effort to recruit diabetic members to the text messaging program varies according to the severity of the disease (because the importance of frequent testing is greater for high-risk diabetics, who may need testing every 3 months).
    • Letter for low-risk patients: Clients with moderately elevated blood sugar levels receive a letter explaining the program and inviting them to join. The letter states, "Reminder text messages will be sent to you about getting a blood test that helps your doctor take care of your diabetes." The letter provides a phone number to call if they are interested in the program. To date, Delaware Physicians Care has received relatively little response to these letters; for example, a mass mailing to 3,000 clients with diabetes resulted in only 45 enrollments.
    • Letter and calls for high-risk patients: Those who have more severe diabetes receive the letter and up to four phone calls from a disease manager. Disease managers ask if the client has a cell phone capable of receiving text messages and if they are interested in the program. Those who are not interested are taken off the recruitment list (these calls typically last 3 minutes or so), whereas those who express interest work with the disease manager to complete an enrollment form. The disease manager also sends documentation of enrollment in the program to the individual's primary care physician. The entire call usually lasts 5 to 10 minutes for those who agree to enroll. To date, these telephone-based efforts have also proven to be difficult. During a recent recruitment effort, for example, nurse managers reached 40 clients by phone (after making an average of two to four calls per client) and signed up only two members for the program.
  • Incentives to enroll: If clients have cell phones capable of receiving text messages, they are offered a $5 prepaid long-distance calling card that can be used anywhere in the continental United States. This card more than covers the cost of receiving text messages from the program, which are estimated to be about $1.50 a year.
  • Confirmation letter: Those who verbally agree to participate are sent a confirmation letter with the calling card. The letter also provides information on how to opt out of the program.
  • Monthly automated educational messages and reminders: The monthly educational messages and reminders to get HbA1c levels tested are automatically generated by Web-based software. The same messages and reminders are sent to all program participants, regardless of how frequently they should have their HbA1c levels tested. When a client has his or her HbA1c tested, the lab performing the test enters the information into a database, which automatically cancels that client's HbA1c testing reminder alerts for the next 6 months. A congratulatory text message is sent to those who are tested, whereas the monthly educational messages continue. A nurse manager tracks participants' HbA1c testing status each week, a process that takes roughly 30 minutes.
  • Expansion to another at-risk population: In addition to expanding the text messaging program to all diabetic members after the pilot study, Delaware Physicians Care now uses a similar approach with pregnant women and new mothers, with educational reminders sent out to schedule and attend pre- and postnatal care visits. Under this initiative, Delaware Physicians has partnered with the largest obstetrics groups in their network, asking them to provide program brochures to appropriate patients and to help in recruiting participants through a Web site accessible to the providers. Obstetricians can also use this site to access the messaging program and send individualized text messages to patients asking them to reschedule appointments that they miss.

Context of the Innovation

Delaware Physicians Care, Inc., a Medicaid managed care organization, serves roughly 80,000 adults and children enrolled in Delaware's Diamond State Health Plan and Delaware Healthy Children Program, which is part of the State Children's Health Insurance program. The organization is responsible for the coordination and management of outpatient, inpatient, and ancillary services for these members. Delaware Physicians is owned by Schaller Anderson of Phoenix, which is wholly owned by Aetna. The text-messaging program was developed in response to the high cost of poorly managed diabetes and the increasing incidence of the disease among the organization's clients.

Did It Work?

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Results

In the pilot study, the program led to a significant increase in HbA1c testing among those who have enrolled. The percentage of participants receiving timely HbA1c tests rose from 52.3 percent at program inception to 70.5 percent 6 months later. This rate is much higher than the 45.4-percent compliance rate achieved by diabetic members not enrolled in the text message program.
  • More frequent testing: Among 105 individuals enrolled in the program, compliance with recommended blood sugar monitoring guidelines improved from 52.3 percent before the program began to 70.5 percent 6 months later. Among nonparticipating members with diabetes, blood testing compliance rates ranged from 37.7 to 45 percent over the same 6-month period. (Data on the impact of the new program for pregnant women and new mothers are not yet available.)

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation testing rates among diabetic participants, along with comparisons to a control group who were monitored during the testing period.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Researching viability of cell phone-based delivery: Investigators at the health plan reviewed published research and determined that a cell phone text-messaging program would be viable for the Medicaid population. (See Adoption Considerations for more information on the research reviewed during this step.)
  • Contracting with vendor: Delaware Physicians hired Medixine, a software company that specializes in communication solutions for health plans, to develop software programs that would automatically send educational messages and text alerts.
  • Developing a recruitment and incentive plan: Program leaders developed a recruitment plan based on mailings and phone calls, along with the phone card incentive plan.
  • Pilot testing and program expansion: The program was pilot tested in the diabetes population for a period of 6 months. Based on the initial success, the program has now been expanded to other clients, including pregnant women and new mothers who receive reminders on the need for pre- and postnatal care and testing.

Resources Used and Skills Needed

  • Costs: Estimated program costs for the pilot program in diabetes were $48,000 per year, or roughly 4 cents per member per month. Costs included phone cards, mailing recruitment and confirmation letters, software development, Web site hosting, and automated message texting. This figure does not include the cost of contacting and enrolling clients by telephone, which, as noted, has proven to be labor intensive. These costs have remained stable for the diabetic program after the pilot study.
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Funding Sources

Delaware Physicians Care Inc.
The program is self-funded by Delaware Physicians Care, Inc.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Determine if the cell phone model is viable: Estimate cell phone usage rates among enrollees to see if cell phones are a viable communications channel for the target population. Medicaid clients can be difficult to contact by mail, and many do not have a land-line telephone service. Research shows, however, that 60 percent of households with incomes of less than $35,000 have cell phones, and the National Center for Health Statistics found that adults living in poverty were more likely than higher-income adults to live in homes equipped with only wireless phone service.
  • Develop a recruitment plan: Determine the most effective way to contact, entice, and enroll clients in the program. A major barrier to recruitment is the lack of accurate mail and phone contact information for many plan members. This information typically comes from the Medicaid enrollment process and is often inaccurate or out of date. Multilingual recruiters may also be needed.
  • Contract with a software vendor: Contract with a software vendor that can implement a text-messaging program, and coordinate with providers or laboratories so that reminder messages can be canceled for a predetermined period of time after clients seek the desired test or service.

Sustaining This Innovation

  • Continuously monitor program impact: Monitor the program's impact on getting clients to seek recommended services (e.g., HbA1c testing). Evaluate whether this impact justifies the ongoing cost of recruitment.
  • Commit to ongoing recruitment: Program sponsors should commit to a continuous recruitment and enrollment effort to sustain the program (which will likely require significant staff time).

Use By Other Organizations

  • Based in part on the success of this program, Aetna plans to use the text-messaging model for patient education and appointment reminders for its diabetic and pregnant clients in other Aetna Medicaid managed care programs across the country.
  • Some providers have also adopted this approach. For example, San Mateo Medical Center in California distributed mobile phones with customized software to young asthma patients, allowing them to communicate with and receive real-time feedback from providers on at least a daily basis. The goal is to promote better management of their conditions, thus reducing costly exacerbations. This initiative is described at http://www.innovations.ahrq.gov/content.aspx?id=1690.

More Information

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Contact the Innovator

Stanley Lynch, MD
Chief Medical Officer
Delaware Physicians Care Inc.
252 Chapman Road, Suite 250
Newark, DE 19702-5406
(302) 894-6753
E-mail: stanley.lynch@aetna.com

Innovator Disclosures

Dr. Lynch has not indicated whether he has financial or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Text Messaging—A New Way for Delaware Physicians Care to Help Its Members. June 30, 2008. Available at: http://www.businesswire.com/news/home/20080630005450/en/Text-Messaging--a-Delaware-Physicians-Care-Members.

Delaware Physicians Care, Inc. Web site. Available at: http://www.delawarephysicianscare.com.

Footnotes

1 Cohen M. Kaiser Commission on Medicaid and the Uninsured: an overview of Medicaid enrollees with diabetes in 2003. October 2007. Available at: http://www.kff.org/medicaid/upload/7700.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 U.S. Centers for Disease Control and Prevention. Eliminate disparities in diabetes. Office of Minority Health and Health Disparities. March 26, 2008. Atlanta.
3 NCQA HEDIS Audit Means for 2007.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 31, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 10, 2010.
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.