Disease State Management Program Focused on Hypertension, Hyperlipidemia, and Diabetes

Objective: To describe the implementation and evaluation of a pilot multidisciplinary disease state management (DSM) program for diabetes, hypertension, and hyperlipidemia at a private, self-insured university (over 900 covered lives). Methods: Enrollees met with a pharmacist, nurse, exercise physiologist, and students in these disciplines to improve clinical outcomes and fitness parameters. Clinical values, quality of life, patient knowledge of disease states, and patient satisfaction were assessed. Results: Of the 20 patients in the pilot program, 17 completed 1 nursing and 2 pharmacist visits; 8 completed exercise physiology visits. At baseline, elevated blood pressure readings were observed in 64.7 % (11 of 17) of patients, 20 % of those with diabetes (1 of 5) had an elevated hemoglobin A1c value (HbA1c), and 82.4 % (14 of 17) had a cholesterol value that was not at goal. At least 1 medication-related problem was observed in 16 patients (94.1%). At 3 months, all patients with diabetes achieved HbA1c levels at or below 7%, 4 patients attained blood pressure control, and 1 achieved normal cholesterol readings. Patients characterized participation in the program as valuable and convenient. Conclusions: Patients involved in the multidisciplinary DSM showed improved clinical outcomes after 3 months. Ongoing analysis of patient outcomes will determine the long-term effectiveness of the DSM