In an effort to improve health outcomes, Harvard Pilgrim conducts ongoing outreach to Medicare Advantage Stride HMO members with diabetes and provides information to providers about their patients with diabetes. This program complements the Million Hearts campaign’s efforts to prevent one million heart attacks and strokes by 2017 by emphasizing a variety of heart healthy behaviors, including blood pressure control, cholesterol management, smoking cessation, and aspirin therapy when appropriate. It also supports the Centers for Medicare and Medicaid Services (CMS) Chronic Care Improvement Plan (CCIP), a five-year project aimed at reducing cardiovascular risk.
The primary components of Harvard Pilgrim’s CCIP program are telephone outreach to Medicare Advantage members with diabetes who are at high risk for complications and the development of a coordinated care plan.
Diabetes management program
Harvard Pilgrim's diabetes management program is designed to help our members with diabetes develop self-management skills to control glucose levels. During member calls, our diabetes nurse care managers:
- Assist the member in identifying lifestyle changes that may prevent chronic symptoms, disease progression, and serious complications
- Discuss medication safety and the importance of continuing to take medications as directed
- Address functional and behavioral health issues
- Assess the patient’s knowledge of diabetes, including his or her understanding of hemoglobin A1c, lipid panel results, blood pressure, diabetes complications and the benefits of regular visits with providers
- Assess the member’s needs, as well as potential barriers to care (for example, income, adverse housing conditions, access to care, etc.)
If you would like to refer a member to our diabetes management program, please call 866-750-2068.
Reports aimed at closing gaps in care
Beginning in June of this year, Harvard Pilgrim will send all Medicare Advantage Stride members a personalized diabetes care report informing them of important diabetes tests/exams, the dates of their last test/exam, and the date that a test/exam may be due based on American Diabetes Association (ADA) guidelines.
Harvard Pilgrim will also distribute a report to primary care providers in September listing the names of their Medicare Advantage Stride patients who may be overdue for a diabetes test or eye exam and may require follow-up based on the ADA guidelines.
Medication adherence report
Twice a year (in January and June), Harvard Pilgrim also distributes a medication adherence report for PCPs listing their diabetes patients with 5 or more prescribers. The adherence report not only reveals medication gaps, but also aids in coordinating care among multiple prescribers.
If you have any questions about these programs, please contact Harvard Pilgrim’s Clinical Programs department at