Mary Gardner, RN, MA, CCM, CDE Program Manager, High Risk Diabetes and COPDXLHealth

Member Management Using TheMed-eXpert System and Med-eMonitor

Patient Appliance

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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

Objectives

The Med-eXpert System

Confidential and Proprietary

Care GiversCare Givers

ADT Monitoring CenterADT Monitoring Center

PatientsPatients

XLHealth Care XLHealth Care ManagerManager

Med-eXpert™ Information Med-eXpert™ Information RepositoryRepositoryMed-eXpert™ Information Med-eXpert™ Information RepositoryRepository

Patient AppliancePatient Appliance

Med-Med-eMonitor™eMonitor™Med-Med-eMonitor™eMonitor™

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Diabetes Members with Heart Failure

• Voluntary agreement

• Provider contact approval

Target Population

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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

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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

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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

Med-eXpert Care Plan Guidelines (cont’d)

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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 AdherenceCare Plan - Goals

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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 collaborationEvaluates need for Social Services referral

Medication/Care Plan Adherence Care Manager Interventions

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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 Plan - Goals

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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

Diabetes Care PlanCare Manager Interventions

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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 - Goals

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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

Foot Exam Care Plan Care Manager Interventions

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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!!

ER Visits and Admissions

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Thank You!Questions?

Mary Gardner, RN, MA, CCM, CDE Program Manager, High Risk Diabetes and COPDXLHealth