Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus

Title: Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus

Purpose: Patients receiving Medicare and Medicaid benefits (dual-eligible) have a higher prevalence of multiple comorbidities, including diabetes mellitus. This same population is less likely to have routine preventative measures completed and a higher incidence of disease-related complications. The purpose of this study is to evaluate the effectiveness of a team-based Chronic Care Management (CCM) program in achieving health outcomes in dual-eligible patients with type 2 diabetes (T2D) and the financial sustainability of a CCM program.

Methods: Dual-eligible patients with T2D meeting CCM enrollment criteria were evaluated in a retrospective, pre-/post- intervention, observational chart review study from March 2019 to August 2021. Statistical analyses using non-parametric tests evaluated clinical outcomes (e.g., hemoglobin A1c), preventative measures and clinical staff encounters. Preliminary financials are reported descriptively.

Results: Twenty-six patients were included in the analysis. There was a significant reduction in mean A1c levels (8.15% to 7.34%, p = 0.035). Changes in preventative metrics included a statically significant increase in statin prescriptions (p=0.039) while a non-significant increase in pneumococcal and influenza vaccine rates and depression screenings is noted. $14,721.00 was billed to insurers for the service with a reimbursement rate of 39.6%.

Conclusion: This study shows that team-based patient care in a CCM program improves A1c levels and supports achievement of preventative measures. Full realization of intervention impact limited by the lack of in-person access to healthcare services due to shutdowns in response to the global pandemic.