The effect of chronic care management on diabetes‐related outcomes in interprofessional care of a medically complex patient population

Introduction Chronic Care Management (CCM) services encourage a team‐based approach to improve care management delivery and related patient health outcomes. However, the literature on clinical and financial sustainability from implementation of CCM services by a collaborative, interprofessional team is limited. This study focuses on evaluating diabetes‐related outcomes of an interprofessional CCM program and calculating the return on investment (ROI) of the implemented program. Methods In a single‐center, retrospective, pre‐/post‐intervention chart review study, adult Medicare Part B beneficiaries with type 2 diabetes (T2D) enrolled in the CCM program from February to August 2020 were evaluated using non‐parametric tests to compare clinical measures, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and clinical staff time‐on‐task 1 year before and 1 year after the enrollment dates. A ROI analysis describes financial outcomes and viability. Results Forty‐two patients met inclusion criteria. The statistically significant pre‐/post‐measures included reduction in glycosylated hemoglobin (A1C) (7.5% vs. 6.8%, p ‐value = 0.003) and the body mass index (BMI) (34.8 vs. 34.0 kg/m 2 , p ‐value < 0.001), and increased clinical staff involvement for pharmacist interventions (9 vs. 36, p ‐value < 0.001) and social worker interventions (1 vs. 24, p ‐value < 0.001). Additional trends included reductions in blood pressure and increases in patients achieving multiple HEDIS measures. ROI demonstrated that every $1 invested in the CCM program returned $1.29 to the clinic, $3.04 when accounting for A1C reduction. Conclusion Incorporation of a collaborative, interprofessional CCM program into a single‐center family medicine clinic proves to have clinical and financial benefits in a medically complex patient population with T2D. The coronavirus disease 2019 (COVID‐19) pandemic that emerged during the study period and a small sample size are identified as limitations to the current study. Areas of future research include interprofessional CCM program impact on comprehensive care management, health equity, and facilitation of care management transition from fee‐for‐service to value‐based care.