NUR 653 Module 9 Final Project Example

Final Project: A Tiered Population Care Management Program for Diabetes and Hypertension

[Student Name]

Southern New Hampshire University

NUR 653: Population Care Management

Module Nine Final Project

[Instructor Name]

[Date]

Final Project: A Tiered Population Care Management Program for Diabetes and Hypertension

Diabetes and hypertension together account for a large share of the preventable heart attacks, strokes, kidney failure and hospitalizations in any adult population, and both respond to steady, well-organized care. Mesa Valley, the composite accountable care organization serving 42,000 attributed patients through eleven practices, has 3,860 adults with diabetes and 11,200 with hypertension, with substantial overlap. Control has barely moved in three years: 42% of patients with diabetes are poorly controlled or untested, and 39% of patients with hypertension are above 140/90. This proposal asks the organization's leadership to fund a tiered population care management program for both conditions. It argues that matching the intensity of support to each patient's need, using strategies with rigorous evidence and evaluating the program fairly, can improve control across the whole population and reduce avoidable hospital use at a cost the shared savings contract can support.

The Population and Its Needs

Registries for both conditions were built with explicit definitions and checked against chart review. The diabetes assessment found that a quarter of patients had no visit in a year, kidney and eye screening lagged at 38% and 44% and poor control was concentrated among Spanish-speaking patients, Medicaid enrollees and two rural practices. A laboratory search found 2,900 adults with prediabetes. Social needs screening in two practices found that 44% of patients with diabetes reported at least one need, most often food insecurity or transportation. The organization's existing telephone care management vendor had shown no effect on hospital use, and its stratification had been based on last year's costs, which the organization's own claims showed would reward regression to the mean.

Three Tiers Matched to Need

Tier one serves every registry patient and every adult with prediabetes. It includes monthly registry refreshes with outreach to anyone overdue, standing orders for kidney tests, retinal imaging and statin prompts, standardized blood pressure measurement with automated devices and self-management education triggered at diagnosis, when goals are not met, when complications arise and after transitions. Patients with prediabetes are invited to a bilingual year-long lifestyle program built on the Diabetes Prevention Program trial, where intensive coaching produced 58% fewer new cases of diabetes than placebo (Diabetes Prevention Program Research Group, 2002).

Tier two serves patients whose A1c exceeds 9% or whose blood pressure remains above target despite treatment. Nurse case managers and a clinical pharmacist, working under protocols approved by the medical director, adjust medications every two to four weeks based on home and office readings until control is reached. This approach draws on the hypertension program reported by Jaffe et al. (2013), in which a large integrated system nearly doubled blood pressure control after organizing care around a population list, a short treatment algorithm, combination tablets and quick nurse-assistant rechecks.

Tier three serves patients with persistent high hospital use or uncontrolled disease combined with social needs, identified by need-based criteria and team referral rather than past cost. Each receives an embedded nurse care manager who is part of the practice team. Brown et al. (2012) found that Medicare care coordination programs that reduced admissions for high-risk patients shared six features: frequent in-person contact, occasional contact with physicians, acting as a communication hub, evidence-based education, strong medication management and timely transitional care. Mesa Valley's tier three is built around those six features, and community health workers join care managers for patients with social needs.

Evaluation

Because tiers two and three have more eligible patients than capacity, enrollment occurs in three randomized waves four months apart, and patients awaiting enrollment serve as a comparison group. Outcomes are analyzed by assignment. Measures follow the Triple Aim: for health, poor diabetes control counting untested patients, blood pressure control and admissions and emergency visits per thousand; for experience, a short coordination survey; for cost, monthly spending per member drawn from claims. Fidelity is measured against the program design, including in-person contacts and transitional care within two days of discharge. Every measure is reported for Spanish-speaking patients, Medicaid enrollees and rural practices, and success requires that none of these groups falls behind the rest.

Costs and Financing

Net new spending is about $683,000 a year after the vendor contract ends. Mesa Valley's average cost for a hospital admission among patients with diabetes or hypertension is about $15,800, so preventing roughly 45 admissions a year would cover the net cost before counting any improvement in quality bonuses under the contract. The evidence suggests this is achievable only if tier three is delivered with fidelity to the six features, which is why fidelity will be reported alongside outcomes.

Table 1. Estimated Annual Program Costs

Note. Existing nurse case managers and medical assistants absorb registry outreach and follow-up visits; figures are first-year estimates.

Governance and Risks

The program will be led by the population care manager, reporting to a population health committee that includes practice leads, the medical director, nursing, pharmacy, a community health worker and two patients. Each practice names a clinician champion who reviews registry results monthly. Risks include practice resistance to standing orders and protocols, care manager turnover, limited Spanish-speaking staff and the possibility that the evaluation shows smaller effects than hoped. Mitigation includes involving practice leads in writing protocols, a career ladder for care managers, recruitment from the communities served and a commitment to treat modest or null results as information for redesign rather than grounds for abandoning population care.

Conclusion

Mesa Valley's registries show thousands of patients with diabetes and hypertension whose care has stalled, concentrated in groups and practices the organization can identify. A three-tier program gives everyone reliable basics, adds protocol-driven titration for those above target and brings embedded care management with proven features and community health workers to those with the greatest need. Evaluated with randomized waves and equity as a criterion, and financed largely by redirecting an ineffective vendor contract, it offers a realistic path to better control for the whole population.

References

Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31(6), 1156-1166. https://doi.org/10.1377/hlthaff.2012.0393

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512

Jaffe, M. G., Lee, G. A., Young, J. D., Sidney, S., & Go, A. S. (2013). Improved blood pressure control associated with a large-scale hypertension program. JAMA, 310(7), 699-705. https://doi.org/10.1001/jama.2013.108769