Program follows members through continuum
Members managed through illness and wellness
Under a new holistic case management program at Regence BlueCross BlueShield, one case manager, called a care advocate, follows members along the continuum of care, no matter what their health care needs.
"We have created a single umbrella of care so that members no longer have to talk to multiple people because they have multiple health care issues. Our main focus is putting our members first. We're not really putting the members first when they call and have to talk to one person about behavioral health, then be transferred to someone else for disease management," says Melanie Westrick, RN, BSN, CCM, CCP, assistant director of health care services for the Portland, OR - based health plan.
The health plan began phasing in the holistic care management program in June 2006, with a goal of being fully functionally in early 2007.
Care management can't be a one-size-fits-all proposition, points out Steven Goldberg, PhD, director of case management/utilization management.
"We can have a diabetic who is relatively healthy and follows his doctor's advice and another diabetic who is a train wreck. There's no single formula for managing these two types of individuals," Goldberg says.
Instead of focusing on a particular disease state, the care advocates focus on each member's individual needs and what areas of the member's health care experience Regence BlueCross and BlueShield can impact, he adds. The care advocates follow members through wellness to illness and back to wellness, working with physicians and other health care providers to tailor an individual treatment plan.
Clinicians who work in the health plan's care management department include RNs, social workers, behavioral health experts, and health coaches.
To identify members for the program, the health plan mines its data using an elaborate predictive modeling system that determines what types of interventions members need, from education to more complex interventions for someone who is acutely ill.
Complex interventions include supporting the member's contact with his or her provider and arranging appropriate care and services.
"We approach our members according to their current state of wellness or illness and what we can do as a plan to support their interaction with their providers," Goldberg says.
Members are assigned to a care advocate who can best meet their needs.
For instance, when members want to stop smoking, they are likely to work with a health coach.
If they have a chronic illness, they'll be assigned to a care advocate who is an RN.
"We assign members to clinicians who can work with members on all their health care needs, throughout the continuum of care," Westrick says.
The care advocates have received extensive training from both internal and external resources and are skilled in motivational interviewing.
"We understand we can't be experienced in everything. Some clinicians are more experienced in certain areas, and we try to assign members accordingly," she says.
When a member becomes ill, the care advocate doesn't deal just with the incident of illness but looks at the member holistically and addresses all of his or her health care needs.
"Rather than looking just at symptoms, we want to understand the entire individual and reinforce a wellness orientation. We focus on the particular disease state as well, but in addition, we look at each member as an individual with unique health care needs," Goldberg says.
For instance, in the case of members with congestive heart failure, monitoring the weight and being compliant with diuretics and other medications are vital ingredients of a health management plan, but there may be other factors that affect their health.
"We look at the treatment plan, but that's not where it ends. What is causing the disease to exacerbate is the key. We look at why they don't fill their prescriptions or why they don't see their doctor regularly and help remove any obstacles for care," Westrick says.
About 70% of medical conditions involve psychosocial issues, such as depression and lack of motivation, Westrick points out.
"In order to better manage the condition, we need to deal with these issues early on in the disease," she adds.
Recognizing the member's behavioral health care needs from day one improves the impact a health plan can have on the member's condition, Goldberg says.
Treating the member holistically means dealing with the mental health issues and the medical issues at the same time, Westrick adds.
"You can't just put someone in a depression program and think that's taking care of the whole person. It might help them with depression, but the reason they are depressed may be that they have a chronic illness. Instead of trying to silo them into a specific disease management program, we look at our members holistically to see where we can help them," she says.
When members are identified for the program, the health plan sends them an introductory letter, a biography of the advocate who is assigned to them, along with business cards and a direct-dial number.
The care advocates get in touch with the members and conduct a standard assessment, which helps them identify the actionable points with each member. They develop a care plan and work with the member to make sure that all of the health care needs are covered.
"We don't just remind them to get their medication filled; we look at why they aren't taking it. If we can identify the reason they aren't compliant and help them with it, we can achieve better long-term success," Westrick says.
The lengthy assessment typically takes place during several telephone conversations.
"It's amazing how much information the clinician can glean just from listening to the member, particularly over time. The more the clinician talks to the member, the more information the member will reveal. That's why a long-time relationship with a member is so important," Westrick says.
The health plan has created Regence RX, an on-line database that members can use to look up their drugs and potential interactions. The care advocate can go on the web site with the members and help them learn to use the database.
The care advocates follow up at intervals based on the members' conditions. "The level of interaction is defined by the acuity level and changes with how the member's condition develops. Sometimes the member needs more interactions, and once it's resolved, the care advocates won't be in touch so often," she says.
They may follow up by e-mail in addition to calling the member on the telephone.
"The assessment helps us understand what kind of information the member wants and how they want to receive it. Some are into health and wellness and want all the information we can give them. Others want to get their information from their health care provider. How we support those two members is very different," Goldberg says.
If a member is going in for a doctor visit and has been newly diagnosed with a chronic disease, the care advocate can help develop a list of questions for the doctor. If someone comes back from a visit and is confused about a treatment plan, the care advocate can contact the provider and get clarification.
"When someone has a chronic illness and visits the doctor, they usually retain only a percentage of the information they are given. Our care advocates support the member's relationship with the provider and help them get the information they need," she says.
The health plan monitors its data on a regular basis, looking for patterns in how individual members are caring for themselves and initiates interventions when changes in health care patterns indicate it.
"If a member whose condition has been stable, suddenly has an emergency room or a specialist visit that would then give the care advocate an opportunity to look at what has changed," she says.
Under a new holistic case management program at Regence BlueCross BlueShield, one case manager, called a care advocate, follows members along the continuum of care, no matter what their health care needs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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