Medicaid patients with diabetes and hypertension need better outcomes. To achieve better outcomes, physicians need more consistent information on their patients’ real health behaviors. State legislators are pressing to get healthcare costs under control, while Medicaid administrators need to invest thinly stretched resources simultaneously in direct care and broad public health programs that will keep hospital readmissions down. As director of a network of managed primary care systems (Northern Piedmont Community Care) serving 60,000 members of North Carolina’s Medicaid population, I must balance these needs daily, as efficiently and economically as possible.

That makes me especially interested in interventions that might meet all these goals. And often, it’s a simple idea that can make a difference. That was the case with a study called CHANGE (Cholesterol, Hypertension And Glucose Education), led by my colleague Dr. Hayden Bosworth at Duke University Medical Center. CHANGE was designed to address the significant disparities in mortality between African-American patients and white patients with cardiovascular disease and diabetes. In the CHANGE intervention, patients recommended by their primary care physicians were called on a monthly basis for a full year by nurses who guided them through discussion modules on topics ranging from weight, diet and exercise to medications, side effects, memory, depression, stress, patient-provider interactions and social support. Trained in motivational interviewing techniques, CHANGE nurses made quarterly reports on patients’ progress and medication issues to primary care providers, keeping them in the loop. The CHANGE pilot study has had encouraging results, showing positive changes in patients’ adherence to medication regimens, A1C blood sugar levels, blood pressure and weight.

Here’s the key: The nurses developed real relationships with their phone patients over the course of the year. Patients began to anticipate their calls, write down questions and feel accountable for the lifestyle changes they discussed. By getting to know these patients better, learning their health behaviors and patterns, the nurses were able to make critical saves. In one case, an amputation was narrowly avoided; in another, a patient with dangerous morning blood sugar levels was found to be drinking large amounts of sweet tea before bed, never considering it part of his “diet.”

It’s a simple idea — more frequent communication yields better data, personal relationships support behavior change — but sometimes it takes a good study to prove it, and move the idea from concept into practice.

I was skeptical about a phone-based system at first. It sounded like a boutique sort of service that was not a good fit for my very low-income patients. But then I saw the results with hypertension at some of the study sites, and I knew that this could be the sort of “bridge” intervention I needed to serve CVD patients of all races. I didn’t want to completely abandon chronic disease self-management programs and move strictly to a focus on hospital utilization. And I was searching for a program that was low-maintenance from a resource perspective but could have a wide impact.

So I’ve brought the program to Northern Piedmont Community Care. In the coming months, the intervention will roll out to all Medicaid practices in the state of North Carolina, potentially serving over one million recipients. It doesn’t happen often enough — seeing good data leave the shelf and be applied in real clinical settings where it can make an impact.

The success of this intervention isn’t hard to understand. And it isn’t the sole answer to the CVD epidemic sweeping the country. But it is an example of good medicine that’s practical, affordable and effective. And sometimes a simple solution is just what we need.

Fred Johnson is Director, Northern Piedmont Community Care, one of 14 networks that are managed primary care systems for the Medicaid patients in North Carolina. CHANGE is a project of Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

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