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Member Management Using The Med-eXpert System and Med-eMonitor Patient Appliance. Mary Gardner, RN, MA, CCM, CDE Program Manager, High Risk Diabetes and COPD XLHealth. Objectives.
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Member Management Using TheMed-eXpert System and Med-eMonitor Patient Appliance Mary Gardner, RN, MA, CCM, CDE Program Manager, High Risk Diabetes and COPD XLHealth
Objectives To provide information on the previous use and implementation of the Med-eXpert System, which links together patients using the Med eMonitor Patient Appliance, the ADT call center, and XLHealth Care Managers
Confidential and Proprietary The Med-eXpert System Patient Appliance Med-eMonitor™ Patients Care Givers Med-eXpert™ Information Repository ADT Monitoring Center XLHealth Care Manager
Target Population Diabetes Members with Heart Failure • Voluntary agreement • Provider contact approval
Med eXpert System What Can It Do? • Patient’s Med-eMonitor linked to Med-eXpert database, appliance sounds an alarm at the time of medication dosage or care plan activity (answer health query, self-care check, clinic visit) • Records when the member takes their medications - it then sends the information to a secure site where a Care Manager will review it • Sends automated alerts if the member is not taking their medications properly, experiences any side effects, or the responses indicate a potential health risk • Information is confirmed with member and appropriate action is taken to facilitate medication adherence
Med-eXpert Care Plan Guidelines Medication - Guidelines • Daily • Reminder(s) to take medicines • Confirm adherence or non-adherence • Solicit reasons for non-adherence • Monthly • Contact to determine if have had: • Any medication changes
Med-eXpert Care Plan Guidelines (cont’d) Intervention - Guidelines • Weekly • Reminder to test glucose, and enter levels into Med-eMonitor appliance • Reminder to follow healthy meal plan • Reminder to inspect feet and wear protective footwear • Monthly • Contact to determine if have had: • Any ER visits this month • Any hospitalization this month
Medication AdherenceCare Plan - Goals Long-Term Goal: • Member will take medications as prescribed by their provider to improve health outcomes and reduce health care costs Short-Term Goal: • Member will adhere to their daily medication regimen as prescribed by their provider
Medication/Care Plan Adherence Care Manager Interventions The Med-eXpert System enables Care Manager evaluation of factors affecting Medication and Care Plan Adherence: • Medication adherence (e.g. side effects, out of meds, etc.) • Financial issues • Poor memory • Complex dosing regimen • Lack of understanding of therapeutic benefit • Barriers to diabetes self-care • Emotional issues Evaluates home support system • Refer to appropriate resources to maintain safe medication administration Maintains provider collaboration Evaluates need for Social Services referral
DiabetesCare Plan - Goals Long-Term Goal: • Member will follow Diabetes care regimen prescribed by their provider Short-Term Goal: • Member visits provider and specialty providers regularly • Member verbalizes understanding of blood glucose targets • Member knows the importance of following an individualized healthy meal plan • Member practices healthy foot care
Diabetes Care PlanCare Manager Interventions Contacts provider for SBGM frequency, if unknown Contacts provider for referral to: • Dietitian • Diabetes Educator • Social Services • Specialty Providers • Endocrinologist, Wound Care Center, Podiatrist, Pedorthist, Vascular Specialist, Opthamologist Educate members to call their provider for: • Significant changes in blood glucose results • Episodes of hyper-or hypoglycemia symptoms
Foot Exam Care Plan - Goals Long-Term Goal: • Will perform daily foot exam • Will wear diabetic shoes and inserts daily • Podiatrist evaluation is complete and will seek a routine podiatry evaluation at least annually/ ≥ 4 times/year • Verbalizes importance of emergent podiatrist appt if rest pain occurs Short-Term Goal: • Verbalizes importance of seeking evaluation within 48 hours of observing foot problem • Will perform daily foot exam
Foot Exam Care Plan Care Manager Interventions Assist member to: • Find a Primary Care Physician, if needed • Find a Podiatrist, if needed • Find a Pedorthist, if needed • Find an LEX vascular surgeon, if needed
ER Visits and Admissions To evaluate: • Member care needs • Regular provider and specialty visits, DME • Healthcare compliance • Medication regimen, self glucose monitoring, healthy meal plan, healthy foot care • Knowledge deficits To facilitate Care Manager interventions To Avoid Hospitalizations and ER Visits!!
Thank You!Questions? Mary Gardner, RN, MA, CCM, CDE Program Manager, High Risk Diabetes and COPD XLHealth