Executive Summary
Triad HealthCare Network’s wellness program attracts enrollees through incentives and then has them meet with case managers in an effort to improve their overall health and lower costs.
- Case managers screen patients for high blood sugar, high blood pressure, and other problems at various quarterly system health fairs.
- The initial, one-on-one assessment includes a full medical history, demographics, education, and goal-setting.
- Case managers provide ongoing case management through regular visits with enrollees.
The Triad HealthCare Network’s wellness program relies on incentives and case management to improve outcomes in reducing hospitalizations, emergency room visits, and costs for a large health system payer’s members.
Several case managers (CMs) handle a 500-plus patient population, handling in-person visits, education, and other services to people with chronic illnesses. The program also works with pregnant women to reduce premature births.
The first step involves outreach: The program attracts members through direct marketing, through pharmacy referrals, and also through health fair screenings, says Geronda C. Pulliam, RN, BSN, MS, CCM, assistant clinical director of care management for Triad HealthCare Network in Greensboro, NC.
“One of the things that makes our program unique is we do face-to-face assessment,” says Janet Hauser, RN, CCM, CDE, RN, care management coordinator for Triad HealthCare Network Care Management.
Pulliam and Hauser offer this look at the case manager’s role in the program:
• Health screenings: CMs visit 10 different health system sites each quarter, providing health screenings between 11 a.m. and 1 p.m. or earlier, Hauser notes.
“We check blood pressure and blood sugar,” she says.
When someone being screened is discovered to have high blood sugar, high blood pressure, or other results indicating a chronic health issue, they are invited to join the Link to Wellness program for disease management services. They’re also offered incentives such as reduced or free medications, free medical supplies, and other free health services, Pulliam says.
• Initial assessment: The initial assessment takes place at the case manager’s office, weekdays, from 9 a.m. to 5 p.m., Hauser says.
On average, a CM will see three patients a day. “The majority of our time is spent meeting with members, and not just employees, but also their spouses and children,” Hauser says.
The CM first has to assess what is going on in the patient’s life.
“They fill out a questionnaire with their medical history and their demographic information and their medication list,” Pulliam says.
The initial visit will take about two hours because it is a hands-on assessment of checking blood pressure and glucose A1C levels, Hauser explains.
Case managers do a psychosocial assessment, including assessing depression. They ask about family history, advance directives, pain, height, weight, etc., Hauser says.
At the first visit the CM also helps members set goals, including goals for the next meeting.
“As nurses, we know what we want our patients to do, but in setting the goal we need to consider what they are willing and able to do,” Hauser explains.
So during the first visit, the CM will help patients set smart goals that are specific, measurable, achievable, and within a specific time frame, she says.
“We make sure members are in agreement and that it feels like this is something they can achieve by the next visit with us, and we give them a little goal sheet to take with them,” she adds.
“We arrange for follow-up before they leave,” Hauser says. “I make sure they can demonstrate how to use a blood pressure monitor or glucometer.”
Hauser hands out information packets about the members’ disease. This packet includes target goals and includes space for documentation of readings.
One of the CM’s goals might be to help the patient make an appointment with a physician and to ask the patient to bring all documented readings to that appointment, Hauser says.
The CM educates the member about dietary changes, reviewing written material and asking the person to review it and follow the recommendations.
“The big thing is exercise, and we talk about that,” Hauser says.
• Ongoing case management: “Subsequent follow-up visits are monthly until the member is stable in his disease process,” Pulliam says.
The program’s participants also are asked to visit the pharmacy to learn more about the medications they’ll be taking, Pulliam adds.
“If they are self-managing well, they are graduated from the program,” Pulliam says.
“Based on where patients are in their self-management skills, we may see them as often as once a month or as infrequently as once every six months, or even once a year if they’re very stable in managing their disease process,” Hauser says. “The goal is to get their numbers to target as set by their physician or by national standards.”
CMs recommend patients engage in education courses, such as the intensive type 2 diabetic core classes, where they can learn the basics of what they need to do to self-manage, she adds.
“We gradually see them less and less and sometimes this stretches out to once a year,” Hauser says.
Some people want to be held more accountable and will see their CM every three months, she adds.
Follow-up appointments last about an hour, but can be longer if the patient has a crisis. Also, CMs will refer plan members to employee assistance programs to meet with licensed counselors, if needed.
“We can check in on people through phone calls, but it’s all based on member need,” Hauser says. “Some people just need more encouragement.”
The Triad HealthCare Network’s wellness program relies on incentives and case management to improve outcomes in reducing hospitalizations, emergency room visits, and costs for a large health system payer’s members.
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