Original Research
Tuesday, November 14, 2023
08:30 AM–10:00 AM
Abstract
Introduction: Chronic Care Management (CCM) programs allow a team-based approach to improve chronic disease state management; however, the literature on clinical outcomes from CCM interventions by a defined interprofessional team is limited. Patients with type 2 diabetes (T2D) often have coexisting chronic conditions requiring greater monitoring, interventions, and follow-up to prevent disease-related complications. This study focuses on CCM-enrolled patients diagnosed with T2D with the goal of evaluating diabetes-related outcomes of a CCM program facilitated by a physician, clinical pharmacists, a social worker and a medical assistant.
Research Question or Hypothesis: What impact does interprofessional chronic care management have on diabetes-related clinical outcomes?
Study Design: Retrospective, pre-/post- intervention chart review
Methods: A chart review of adult Medicare beneficiaries with T2D enrolled in CCM from February to August 2020 was completed with outcomes evaluated via non-parametric tests to compare clinical measures, preventative measures, and clinical staff time-on-task 12 months before and after the enrollment date.
Results: Forty-two patients met inclusion criteria. Statistically significant pre-/post measures included reductions in A1C (7.5 vs 6.8%, p-value = 0.003) and BMI (34.8 vs 34.0, p-value < 0.001), and increased clinical staff involvement for pharmacist interventions (9 vs 36, p-value < 0.001) and social worker interventions (1 vs 24, p-value < 0.001). Clinically significant measures included reductions in blood pressure, achieving A1C < 8%, and attainment of multiple preventative measures. A majority (87.4%) of CCM services offered were facilitated by clinical staff members.
Conclusion: The interprofessional CCM program for patients with T2D proves to have clinical benefits in a medically complex patient population. Although limitations emerged from the study period overlapping with the COVID-19 pandemic, this study highlights ample opportunity to further analyze the impact CCM programs may have on the overall health of patients with chronic conditions. Further studies in non-pandemic conditions would likely be useful.
Presenting Author
Megan Wesling Pharm.D., BCPS, BCACP, CDCESUniversity of North Texas Health Science Center at Fort Worth
Authors
Ashlyn Aguiniga Pharm.D., BCACP, CDCES
University of North Texas Health Science Center at Fort Worth
Didi Ebert DO, MPH, MS, CPPS, FAAFP
John Peter Smith Health Network