Harnessing Health Information Technology for Self-Management Support and Medication Activation in a Medicaid Health Plan

The prevalence of diabetes is increasing across the U.S., and evidence suggests significant and widening disparities in prevalence, quality of care, and clinical outcomes by race, ethnicity, language, health literacy, educational attainment, income, and insurance status. For people with chronic diseases such as diabetes, limited health literacy and language barriers place them at higher risk for suboptimal communication with their providers about topics that are crucial to patient-centered care. In addition, patients with chronic illnesses appear to experience greater medication miscommunication, which can compromise patient safety in the context of chronic disease management.

The Self-Management Automated Real Time Telephone Support (SMART-Steps) program enhanced an automated telephone self-management (ATSM) support system to provide surveillance, education, and additional telephone care management guided by questions on patient behavior. The primary goal of this evaluation study was to determine whether ATSM improves quality of life and self-management among diverse patients with diabetes in a Medicaid and low-income health plan. The specific aims of the study were to:

• Measure the effects of a Medicaid health plan-directed ATSM on patient-centered outcomes among ethnically-diverse health plan enrollees with diabetes.
• Explore whether combining ATSM with an additional patient-directed health information technology innovation—a medication activation communication strategy triggered by pharmacy claims data—yields differential effects on patient-centered outcomes compared to ATSM alone.
• Quantify and characterize patient safety events triggered and/or identified through active surveillance among ATSM participants.
• Measure differences in the frequency and nature of patient safety events among participants receiving ATSM-only versus ATSM-plus medication activation.

Researchers from the University of San Francisco partnered with the San Francisco Health Plan (SFHP), a Medicaid plan, to implement two forms of ATSM. The first (ATSM-ONLY) provided automated queries and messages combined with health coaching. The second (ATSM-PLUS) also leveraged pharmacy claims to strengthen medication counseling. Through a quasi-experimental study design, the project team examined the effects of the intervention among SMART-Steps program participants from SFHP. Enrolled patients were randomized to ATSM-ONLY, ATSM-PLUS, or usual care.

The study enrolled 362 members with 79 percent reporting incomes less than or equal to $30,000. Sixty-eight percent reported limited English proficiency: 19 percent spoke Spanish and 54 percent spoke Cantonese. Engagement was high: 85 percent participated in more than one ATSM call, with the median number of calls being 20 calls over 27 weeks. Those exposed to ATSM had significantly better glucose monitoring, foot care, and diabetes self-care behaviors as measured by the diabetes self-care activities questionnaire.