New approach helps members manage disease
December 1, 2003 6 minutes read
New approach helps members manage disease
Program integrates DM, decision support
Independence Blue Cross takes a three-pronged approach to helping members manage their health care with its newly expanded ConnectionsSM Health Management Program.
The program uses specially trained clinicians, called health coaches, who help members to better understand and manage their chronic diseases, and make effective choices with their physicians when they are faced with a health care decision. They also answer questions about everyday medical concerns.
"We believe our program is on the leading edge because of its scope and integration. The program covers all five major chronic diseases, and it integrates disease management and decision support," says Esther Nash, MD, senior medical director of the Philadelphia-based health plan.
The health plan has been providing population-based disease management and disease-specific case management since the early 1990s and has dramatically expanded the services this year, she adds.
"The program offers something for everyone — patients who have a chronic condition, those who are facing an acute problem, and people who have everyday health concerns," Nash says.
The disease management component provides support services for members with five chronic conditions: asthma, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, and diabetes.
A proactive approach
The health plan estimates that members with those ailments account for 24% of medical costs for the commercial products and 55% of medical costs for Medicare products. More than 33% of its Medicare population has at least one of the five chronic diseases.
"There is evidence that people who participate in a program like Connections can change their behavior and experience fewer complications and hospitalizations due to their medical conditions, improving their quality of life and lowering overall health care costs," Nash says.
Members who are facing serious health care decisions, such as whether to have back surgery or what to do concerning newly diagnosed breast cancer or prostate cancer, can talk to the health coaches and get information about various treatment options and how to discuss their options with their physicians.
"This program is designed to help members increase the quality of their health care by taking a proactive approach to their conditions," Nash adds. "Knowing the right questions to ask and then partnering with a physician to make the right care decisions is an important part of quality care."
Members who have everyday medical concerns or questions can call a health coach with questions and receive educational materials mailed to their home or through the Healthwise Knowledgebase on the Internet.
"Integration is one of the major strengths of the program," Nash comments.
The health coaches use a system that tracks all the interventions anyone has with the member.
The program is integrated with other health plan medical management programs such as weight loss and fitness programs, intensive case management, concurrent review, and pre-certification, through an extensive database.
All of the health coaches are licensed clinicians. Most are RNs, but nutritionists and respiratory therapists also serve as health coaches.
In addition to training in the targeted clinical conditions, the health coaches go through training in patient engagement, recognizing behavioral cues, and shared decision-making techniques.
"This underlines the decision support this model provides. When we are faced with medical decisions, all of us as patients can make the best decision when the decision making is shared between doctor and patient," Nash says.
The patient engagement training helps the health coaches understand that patients may be in different places psychologically at different times and under different circumstances. The health coaches learn to recognize behavioral cues while they are talking with the members so they understand the most effective way to approach the member, she adds.
The health coaches are cross-trained in all three components of the system so that the same health coach deals with the same members no matter what their needs. When a member needs additional help from a specialist, however, the RNs can call in the respiratory therapist or nutritionists for a consultation.
"We place a value on the personal health care relationships. It’s important for the member to know the name and direct phone number of their personal health coach rather than being referred around," she says.
When members are identified for the chronic conditions program, the health coaches customize the intervention schedule to meet the needs of each patient.
The health coach and member set goals based on medical evidence. For instance, if medical evidence has shown that people with congestive heart failure benefit more from being on an ACE inhibitor than from having another intervention, the health coach makes sure that ACE inhibitors are the first topic covered with the member.
"There is only so much you can cover in a 30-minute call. What comes up is prioritized, and it’s different for each patient, depending on what condition and what combination of conditions they have," Nash says.
The program was purposely designed to be without an endpoint.
"We may decrease the frequency of outbound calls and re-stratify the member, or they may move from being telephoned to getting mailings. The only way members leave the program is to voluntarily opt out or to leave the health plan," she says.
The health plan uses medical and pharmacy claims, utilization information, laboratory results, and risk assessment data to identify members who may benefit from the program. All members receive information on how to access the program. Higher-risk members are called by the health coaches, who discuss the program with them individually.
For the decision support component of the program, the health plan looks for patterns in claims and admissions data to determine when a member may be facing a major health care decision.
For instance, there may be a patient who had an orthopedic consultation, followed by three months of physical therapy, visits to a chiropractor, and an MRI of the back.
"This trail of interventions makes it highly likely that the member may be facing a decision about back surgery," Nash says.
In that case, the health plan would send the member information reminding him or her of the decision support services.
"Our philosophy is that the best time to get information into the hands of the member is early in the treatment process, before they have made a decision to schedule surgery," she adds. "We repeatedly take steps over time to make members aware of these services, in hopes that they will call us even if we haven’t yet found them. We make the doctors aware of the services so they can refer patients as well," Nash reports.
When the plan launches the program for a new segment of its population, all members receive a refrigerator magnet reminding them of the services.
"They may not need it the day the mailing comes in, but our goal is to keep their awareness high so they can call in whenever they feel a need," Nash says.
Members receive regular mailings about the program and may call in and ask to participate. The plan has informed physicians about the program, set up a hotline number for physician questions or referrals, and has provided physicians with referral cards for patients they think will benefit from the program.
The health plan rolled out its program by phases, starting with the Pennsylvania Medicare population on July 1, followed by preferred provider organization-insured members in Pennsylvania in October. The program will be available in January to commercial HMO members and self-funded employers.
It will be more than a year before Independence Blue Cross has outcomes data to demonstrate the effectiveness of the program, but already there are indications that it will be a success, Nash says.
All members who are identified for the chronic disease management program have an opportunity to opt out, but less than 1% have chosen to do so.
Members have reported that they like the program, and usage rates are high.
When the program was rolled out to the Medicare population, the health plan set up a comment line where members could call with comments about the program. So far, out of 70 calls received, 69 were overwhelmingly positive and the other was a misdirected call.
Independence Blue Cross takes a three-pronged approach to helping members manage their health care with its newly expanded Connections SM Health Management Program.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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