Get involved with disease management efforts
Coordination is the key to success
Your company has contracted for disease management with an outside vendor. That puts you out of the loop, right? Wrong, says Derek Newell, vice president of marketing for LifeMasters, a San Francisco-based disease management company.
"Disease management should be tightly integrated with case management. Working together can add a lot of value to the relationship. There will be lost opportunities if case management and disease management work separately," he adds.
LifeMasters provides population-based disease management to health plans, managed care firms, and indemnity preferred provider organizations (PPOs). The company offers disease management for asthma, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, and hypertension.
A few years ago, disease management vendors and case managers tended to view each other as competition and went their separate ways. But, in the last year, there has been a tremendous increase in the number of case managers who are involved in the disease management process, Newell says.
Case managers are becoming more involved in the disease management vendor selection process because payers are realizing that disease management efforts are not as successful if they aren’t integrated with case management, Newell says.
The winners in the long run are the patients, who get better care and better management of their chronic diseases, he says.
"We’re seeing a high degree of involvement with case managers or supervisors of case management in the selection process and in the referral process. Working together with our partners is a key success factor in any disease management program, and that needs to occur at the case management level," Newell says.
In the past 18 months, Newell has noticed that many insurers looking for disease management vendors are including case managers or heads of case management departments on their selection committees. In the past, it was a rare occurrence. Case managers at the 16 major health plans with LifeMasters contracts are sending about 12 referrals a day to disease management programs, and the number is increasing rapidly, he says.
"Last year at this time, we probably got one referral a day from case managers," he adds.
Referrals from case management are particularly important to the success of a disease management program because they usually are highly qualified referrals — patients who are appropriate for the program, need the program, and are predisposed to participate. "These are key component for success in disease management," Newell points out.
More importantly, patients referred directly by case management get into the program early on, rather than when they are selected by retrospective review of their claims data, he points out.
"Case managers find people in real time. Claims are always delayed. Case managers refer to us if they feel that our program is appropriate for a patient who has just been diagnosed with a condition or who has just gone into the hospital," Newell says.
Patients who are referred by case managers tend to be more compliant because their trust in their case manager and insurer is transferred to LifeMasters, Newell says. Newell urges case managers to get involved in the disease management process, making sure the vendor will work closely with case managers to integrate the two functions. "Really, both are part of the continuum of care. There is no way without us that case managers can manage an entire population," Newell says.
A partnership between a company’s internal case managers and a disease management vendor can benefit both groups, Newell says.
Advantages of a DM program
Disease management can be an extension of the case management department by dealing with a population that case management simply can’t reach, freeing the internal case managers to spend their time working with the most severely ill patients who need high-intensity coordination.
"Disease management is not a replacement for case management at all," Newell says. "We have the technology and solutions and scale that allows us to handle more patients and leave the case managers free to take care of the more severe cases." When patients have an acute episode of care and need more personalized interventions, the disease management company will hand them over to the internal case manager until the situation is stabilized, Newell says.
"With the most critically ill patients, we work closely with case management at the insurance company and hand them over for a while. When they become more stable or have gotten through the benefits maze, they may need to move the patient to a lower level intensity," Newell says.
Each plan that contracts with LifeMasters has an internal set of protocols for referring patients between internal case management and the disease management program.Case managers often can be helpful to the patient when a clinical intervention needs to take place, Newell says.
"We make clinical suggestions but not clinical judgments. Case managers can be more aggressive about how they think the case should be handled," he says. About 75% of the time, the patients’ physicians respond to suggestions for changing medication and bringing the patient to the office, Newell says.
LifeMasters uses a claims-based analysis to identify participants. The company calls participants, urging them to enroll and assesses their severity. Depending on their answers to the assessment questions, they may be selected to participate in the program.
Patients with severe conditions transmit their vital signs daily to LifeMasters’s web site, where they are monitored by registered nurses.
"If a patient is having a clinical event, as defined by their physician, the LifeMasters nurse is alerted, and she alerts the physician to the situations," Newell says. The more seriously ill patients receive regular telephone calls from the LifeMasters nurses.
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