Program cuts CHF members' hospitalizations
Holistic approach helps members manage condition
Members with congestive heart failure experienced fewer hospitalizations and emergency department visits and better medication compliance after they began participating in a comprehensive care management program offered by Health Alliance Plan (HAP).
For instance, hospital admissions decreased by 65% among commercial insured members who participated in HAP's HealthTrack heart failure case management program, compared with hospital admissions before the program started. Among senior members, hospitalizations decreased by 56%.
Emergency department visits declined by 50% for commercially insured members and 48% for seniors. Compliance for ACE inhibitors and angiotensin II receptor blockers (ARB medication) among heart failure patients increased from 38% to 78% in the first year of the program.
HAP's HealthTrack is a comprehensive chronic care program that helps members comply with their treatment plans and learn to better manage their conditions, says Rick Precord, MSW, director of clinical care management at the Detroit-based health plan.
The program provides care management for members with heart failure, asthma, diabetes, chronic obstructive pulmonary disease, and coronary artery disease.
"We take a comprehensive and holistic approach to patient care. We look at other comorbid conditions, not just heart failure. Our goal is to support the patient-physician relationship and to support the physician's plan of care for the member," says Precord.
Each month, the health plan analyzes medical claims data, laboratory claims, including lab values, and pharmacy claims to identify members with gaps in care and other risk factors.
The names of members who are identified as being at high risk are forwarded to an outside vendor, which uses a predictive dialer system to call the members. Customer service representatives from the vendor company tell the members about HAP's HealthTrack program and set them up with a telephone appointment with one of HAP's in-house nurse case managers.
For example, members who haven't filled a prescription for an ACE inhibitor or ARB are targeted for a personal phone call.
Members who have been hospitalized are referred immediately to a case manager for intensive interventions.
"We try to schedule all members identified with gaps in care for an appointment with a nurse. Our goal is to get as many as possible scheduled for phone calls," Precord says.
The case managers conduct an extensive assessment that includes a falls risk assessment for elderly members.
Using the member's medical history, utilization, pharmacy data, and laboratory reports, the case manager works with the member to establish a plan of care.
"When members leave their physician's office with a new diagnosis of heart failure, they are overwhelmed with information about the impact of the illness and their treatment plan. The case managers work with them to help them understand and manage their disease," Precord says.
They educate the members on heart failure, the importance of medication compliance, weighing daily, and following up with the physician.
"They do a lot of coaching, helping members set plans and goals and steps to achieve them. They do a lot of work helping members understand what to do when heart failure symptoms get worse," Precord says.
Screening and monitoring
Because there is a high incidence of depression in patients with chronic diseases, all members are screened for depression. Those who screen positively are referred to a behavioral health specialist who works on the same floor as the nurse case managers.
"Many of our members are struggling to manage their conditions, and depression only makes it worse. When they receive appropriate treatment for depression, we've found that they are better able to manage their conditions," Precord says.
The case managers also work with the pharmacy staff if there are medication questions. HAP pharmacists may get in touch with the member's physician if there are medication gaps.
The health plan sends eligible members an in-home monitoring device that plugs into the telephone line and relays the members' answers to a daily series of questions back to HAP.
The health plan provides scales to members who can't afford them and urges the members to weigh themselves daily and enter their weight into the home monitoring device, along with answers to several questions that change daily.
For instance, the heart failure in-home monitoring device records the member's weight and ask a series of questions about diet, exercise, and the member's understanding of his or her disease.
Case managers can use the data from the monitoring device to tailor their next intervention.
If there are indications that the member needs immediate attention, such as weight gain, a red flag appears in the case manager's membership list, alerting the nurse to call that member.
"The monitoring device allows the case managers to manage more members and to keep closer tabs on their needs. When they pull up their list of members using [the device], red flags come up automatically and they know to call that member that day. Otherwise, they may have scheduled a call for the next week and missed an opportunity to prevent an emergency room visit or hospitalization," Precord says.
For all conditions in HAP's HealthTrack program, the health plan sends a letter to members' physicians with the results of the case manager's assessment and sends physicians an annual report showing claims data, tests, and services, as well as gaps in care.
For instance, if a member hasn't been prescribed a beta-blocker or ACE inhibitor or hasn't filled the prescription, the case manager notifies the physician. If they have an urgent concern about the patient, they call the physician.
The case managers establish a relationship with the member that enables them to help the member meet his or her goals.
"Developing a rapport with members goes a long way to helping them overcome barriers to compliance," Precord says.
Whenever possible, the health plan refers members to its web site for comprehensive information about chronic conditions along with action plans and an interactive on-line tool that promotes health care behavioral changes.
Weight management, nutrition, smoking, and stress are among the topics on the site, which includes interactive tutorials and an action plan risk assessment.
If a member doesn't have access to a computer, HAP sends him or her written information about the disease.
In addition, HAP offers members the Personal Action Toward Health (PATH) self-management program for people with chronic diseases. HAP staff have been trained on the program, developed by Stanford University, and present six-week classes free to members at locations throughout the health plan's coverage area.
Members with congestive heart failure experienced fewer hospitalizations and emergency department visits and better medication compliance after they began participating in a comprehensive care management program offered by Health Alliance Plan (HAP).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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