Diabetes-Related Outcomes of an Interprofessional Chronic Care Management (CCM) Service in Medicare Beneficiaries




Rodriguez, Emmanuel
Wesling, Megan
Nguyenly, Angel
Ebert-Blackburn, Didi
Aguiniga, Ashlyn


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Purpose: Patients with type 2 diabetes (T2D) often have coexisting conditions requiring consistent monitoring and preventative measures. Chronic Care Management (CCM) is a Medicare program that aims to improve chronic disease state management, however literature on clinical outcomes is lacking. The purpose of this study is to evaluate the diabetes-related outcomes of an interprofessionally-delivered CCM program in patients where Medicare is the singular payer and secondarily, its financial impact.

Methods: Adult Medicare patients with T2D enrolled in CCM between February 2020 and August 2021 were included in this retrospective chart review. Participants were evaluated pre- and post-CCM enrollment using non-parametric tests on 1) clinical measures such as A1C; 2) preventative measures; and 3) involvement of clinical staff such as pharmacists and social workers. Descriptive statistics were used to describe financials.

Results: Thirty-three patients were included in the study. Changes in clinical measures included a significant reduction in mean A1C from 8.4% to 7.4% (p=0.012), and a nonsignificant reduction in blood pressure and body mass index. There was also a significant increase in pharmacist and social worker involvement, but no significant changes to preventative measures. A total of $26,673.00 was billed to Medicare, with a reimbursement rate of 44%.

Conclusion: The CCM service demonstrated a significant reduction in A1C and a significant increase in pharmacist and social worker access. There were no significant changes in preventative measures, likely due to the overlapping study period and COVID-19 pandemic. Future studies outside of pandemic conditions are needed to further assess these nonsignificant outcomes.


Research Appreciation Day Award Winner - HSC College of Pharmacy, 2023 Clinical/Outcomes Research Award - 2nd Place