Chronic disease management

This project will evaluate the impact of two practice innovations (a telephonic disease management program and intensified nursing interaction) for patients with diabetes by comparing outcomes in three groups: community patients who receive the nursing intervention but not the telephonic component, employee-patients who receive both interventions, and patients who received neither component (historical controls). The two practice innovations are components of a disease management program that is currently being implemented. The evaluation is based on observational data obtained from patients’ medical records and via surveys.

Three types of outcome measures will be used: percent of patient who are high-users of medical care, percent of patients who are highly satisfied with the medical services they receive, and clinical outcomes as measured by HbA1c, blood pressure, cholesterol and body mass index. Patient satisfaction survey questions normally asked of a sample of Mayo patients will be administered to patients enrolled in the telephonic component. The utilization data will be gleaned from the medical record by trained abstractors using an abstraction form. Clinical outcomes will be obtained from the diabetes registry file (DEMS). Data on historical controls will be obtained from medical records. All outcome variables will be measured six months after enrollment.