Program combines face-to-face, telephone consults
Pilot focuses on diabetes, congestive heart failure
A comprehensive program that includes face-to-face assessments and telephonic health coaching is helping Medicare beneficiaries in Tennessee with diabetes or congestive heart failure learn to manage their health.
The program, operated by Baltimore-based XLHealth is one of eight pilot projects selected by the Centers for Medicare & Medicaid Services (CMS) to improve the health of Medicare beneficiaries.
XLHealth's model takes a team approach to care coordination. The participants' personal support team includes a local program manager, a personal support nurse who meets with participants face-to-face, a telephone coach nurse, and a local pharmacist, all of whom work together to support the physician's care plan.
The program started in January and is not yet able to release any outcomes. However, XLHealth has reported significant savings with other health improvement programs serving a senior population.
For instance, over a four-year period, XLHealth's programs targeting a senior population for one client reduced heart bypass surgery rates by nearly 60%, amputation rates by more than 55%, and renal failure admissions by more than 45%.
"We are confident we can have the same results again, but it's too soon to have definitive information. We know that with better management of their health, participants can reduce their incidences of hospitalization," says David Hollis, MD, chief medical officer of XLHealth's Medicare Health Support program.
The pilot project is being conducted in eight sites throughout the state of Tennessee and offers health support services for up to 20,000 fee-for-service Medicare beneficiaries in cities and rural areas who have significant medical costs exceeding the average for those two conditions. Another 10,000 people are in a control group, Hollis says.
Local care managers, called personal support nurses, lead the personal support team and work closely with the telephonic nurse health coaches in a remote call center and local pharmacists who work for two major drug chains under contract with XLHealth.
"The personal support nurses live in the local market and know the physicians in that area. They have the knowledge and the ability to interface with resources in the local community. The telephone coach nurse is not in the local market but works closely with the local nurse to coordinate the care," Hollis says.
Hands-on experience
Participants in the program are encouraged to come into their local assessment center at least once a year for a face-to-face, says Judy Black, RN, program manager for Middle Tennessee.
"We like to bring people in so we can have hands-on experience with them. There is a lot you can do by telephone, but some things, such as physical assessments, must be done in person. They have a choice to have a nurse visit their homes, but there are some things we can't do in the home," she says.
When a participant joins the program, the personal support nurse conducts a physical assessment that includes weight, blood pressure, brachial indexes, and neurological functions.
The nurses are trained to conduct digital retinal photography examinations and transmit the data overnight to the Wilmer Eye Clinic at Baltimore's Johns Hopkins Medical Center, which returns the results within two days.
"The percentage of people who have these exams in Tennessee is alarmingly low, and retinopathy is a huge problem among diabetics. About 9% of our participants so far have had an urgent referral to a retinal specialist because they were in danger of losing their sight," Black says.
Physician visits
The nurses encourage participants to see their physicians on a regular basis so that potential complications can be identified early on before the participants become ill. They give participants tools to take home with them so they can continue the assessment daily.
For instance, diabetics who have peripheral neuropathy receive a temperature probe and are asked to test each foot each morning to detect a temperature greater than 90 degrees or a difference of four degrees.
"An elevated temperature is an indication of potential inflammation, which could lead to skin breakdown and ultimately an ulcer. Patients are instructed to watch for this and stay off their feet for 24 hours if it occurs and then retest. If the temperature remains high, they are instructed to see their doctor," Black says.
Facilitating care
The program works with a pedorthist who comes to the site and fits participants with protective shoes if they need it.
"We make sure they have shoes that fit and that have protective inserts so their feet will be protected. We also test for peripheral artery disease since lack of circulation stops the healing process. It's important that diabetics have shoes that fit so they won't develop a blister or ulcer that won't heal," Black points out.
Anyone who is fitted with special shoes comes to the center three times in the first month so their shoes can be checked to make sure they fit properly.
The nurses empower members to work with their physicians to get control of their conditions.
"The health care delivery system can be very cumbersome for people with chronic conditions. Participants have to figure out what doctor they need to see and when and have the visit before they end up having an amputation or losing their eyesight. Our goal is to identify any problems early on and help the participants get them treated," she says.
They facilitate physician appointments when necessary and check back after the appointment to find out if the patient understands any changes in the treatment plan.
The nurses provide participants with an "Ask-Your-Doctor" letter that lists questions that should be answered on the next visit and sends a copy to the physician so that he or she will be ready to answer the questions and will bring up the subject if the patient doesn't ask.
"We provide the physician with the information we have collected as well. We make it clear to the physician that we are not providing medical care. We provide education, empowerment, and tools that the participants can use to manage their own health and work with the physician to make sure the participants get the care they need," Hollis says.
Participants speak one-on-one with a local pharmacist, either face-to-face or by telephone. The pharmacist uses the opportunity to educate the participants on their medication and the importance of taking it as prescribed, Hollis says.
The pharmacists conduct a review of every medication in the participants' records and ask them to bring in whatever they are taking. They look at the possibility of side effects and medication interaction and make sure that the dosage of each medication is appropriate for the age and size of the patient, Hollis says.
If medications or dosages are not appropriate or recommended medications are not being prescribed, the pharmacist flags them as potential opportunities for follow-up with the patient's physician. XLHealth sends the physician a letter that lists all the medications the patient is taking and suggests that the physician consider giving other medications, based on evidenced-based medicine.
"Many of the participants are seeing more than one physicians and are receiving duplicate doses of the same category of medicine. The pharmacy review uncovers this and gives the physicians the opportunity to discontinue one of the medications," Hollis says.
Teamwork a must
The local care managers and telephonic coach nurses work as a team to help the participants learn to manage their disease.
The local care managers conduct the face-to-face interviews, follow up when necessary, and work with the primary care conditions.
"We know the doctors who are treating the participants and have a relationship with them," Black says.
The telephonic nurse coaches do most of the coaching that helps participants make lifestyle changes that will help keep their conditions under control.
They share information about their clients via computer, and each has access to the other's input into the patient record.
The computer system has a component that guides the discussion, based on what the last nurse who talked to the patient identified as high-priority items. The nurses have the ability to override the system if the patient has a topic that is important that day.
"We drive the discussion according to the patient's particular needs. If something is bothering them today, they can't think of anything else, and that's what we deal with," she says.
The center has an opening each day for six participants per care manager.
"This allows them administrative time to take care of paperwork and follow-up calls," Black says.
A comprehensive program that includes face-to-face assessments and telephonic health coaching is helping Medicare beneficiaries in Tennessee with diabetes or congestive heart failure learn to manage their health.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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