Longitudinal Care Management for Diabetes and Hypertension

Addressing common sources of chronic disease leads to improved patient health, as well as presenting a scalable target for the improvement of value-based care outcomes. Improving patients' self-management skills and quality of life is the key goal of chronic disease management. Mitigating high-costs and slowing disease progression create mutual success for both patients and health care systems. By training nurses to deliver a refined model of longitudinal care management, Corewell Health West was able to achieve improved chronic disease control and create additional capacity among primary care providers. The initial focus of the longitudinal care program was diabetes and hypertension management. Corewell Health created a Multidisciplinary Approach to Disease Over Time (MADOT) framework to guide care management for patients with multiple chronic conditions or who are facing long recovery journeys. The framework emphasizes timely and actionable patient identification, regular contact between patients and health care staff that prioritizes patient goals and assesses their "readiness to change," and specialized skills development for health care staff. The framework has shown success among patients with uncontrolled diabetes (A1c ≥8.0). Of the targeted interventions carried out for more than 1,000 patients since January 2022, 608 patients fully completed the program; these patients demonstrated an average 2.24-percentage point reduction in hemoglobin A1c. Of those 608 patients, 364 had a pre-intervention hemoglobin A1c level ≥9.0 and achieved an average 3.02-percentage point reduction in hemoglobin A1c. Similarly, patients who graduated from the program saw greater improvement in systolic blood pressure than patients who disenrolled or declined interventions.