Initiative achieves high return on investment
CMs coordinate care through the continuum
A combination of short- and long-term case management coupled with an intensive disease management program has paid off for CIGNA Healthcare.
CIGNA reports a 5:1 potential return on investment for case management services on actively managed cases.
In addition to its Well Aware disease management program, CIGNA has on-site review nurses in hospitals and CIGNA nurse case managers who manage the care of patients needing more intensive interventions.
"We want to make sure our members get the care they need, whether it’s long-term or short-term case management, whether they are well or in the hospital," says Joy Bazo, RN, CMC, LHRN, on-site nurse manager for CIGNA at three hospitals in the Tampa Bay, FL, area.
CIGNA’s multifaceted case management program is the result of the health plan’s goal to meets its members’ needs throughout their lives and across every continuum of care, Bazo says.
For example, a child with asthma initially is referred to the Well Aware disease management program. If he ends up in the hospital, an on-site case manager such as Bazo is likely to visit and work with his family in planning what he should do after discharge. If he’s hospitalized more than three times, he’s referred to the in-house case managers for intensive case management after discharge.
"There is good synergy among all three programs — the on-site review nurse, the CIGNA nurse case manager, and the disease management programs. Our focus is on total health. The goal is for our members to stay healthy so they won’t be back in the hospital," adds Colleen Meicke, RN, CCM, a CIGNA in-house case manager based in Tucson, AZ.
Bazo typically visits the patients in the hospital, helps ensure the member understands the care prescribed by the physician and treatment team, talks with their physicians and treatment team, helps coordinate discharge needs and goals, and makes referrals to other CIGNA programs or to community resources based on the recommendation of the member’s physician.
Her goal is to see members within 24 hours of their hospitalization. If members are having pre-planned surgery, Bazo visits them the day after surgery.
"I look at whether they will need short-term or long-term case management, depending on the disease process, and make those referrals to case management so we can coordinate even from the hospital setting what the member will need down the road," Bazo says.
She works with the treatment team and the family to make sure discharge planning is carried out in a timely manner and makes sure that the patient’s discharge needs are in place.
"All case managers, whether they are in touch by phone or in the hospital, work with the family to make sure they understand the member’s condition, the treatment requirements, and the types of services they will need," Bazo says.
Meicke, a case manager for CIGNA, works with the on-site nurse who is handling the member in the hospital. She gets involved by telephone with members to assess what the patients will need when they get home, coordinate care with their physician, and arrange for appropriate post-hospital care.
"My predominant role is follow-through in the long term. It could be very brief or it could be long term when a member has multiple diagnoses or complicated diagnosis and needs quite a bit of intervention," she says.
When Meicke begins working with a patient with a chronic disease, she makes an assessment that includes how much the patient knows about his or her disease and how much medical care the patient has been getting. She talks with the physician to help identify any treatment goals.
"It’s a three-way process. The physician, the patient, and I identify goals and set up a plan that outlines what the patient will do, what I will do, and how we will interact," Meicke says.
She makes sure patients gets the recommended follow-up examinations, know about their diet and medications, and finds out if there are financial problems or other issues that would affect their compliance with the treatment plan.
When a patient seems to be stable, she refers him or her to CIGNA’s Well Aware disease management program.
In Arizona, CIGNA has a new program, Treatment Options Support, a nursing line that helps patients choose from options available to them for that disease.
"As an advocate for them, I want to help empower them to take advantage of all the options they have from CIGNA and in the community," Meicke explains.
People with complicated diseases may have needs that go beyond what CIGNA covers or provides — help with transportation, for instance.
Meicke helps them get whatever they need, works with the family and the patient’s physician, and follows up for as long as they need care.
Meicke helps them become enrolled in community programs that can help, such as support groups in their neighborhood. While CIGNA wants to encourage people with chronic diseases to move into disease management programs that provide added support and education for those with certain illnesses, the case managers still are available if they need more frequent contact and intervention.
"I am their case manager to assist them, help them heal, prevent recurrence, and help them return to their previous healthy state if possible. If it’s not possible, I help them deal with the illness they have and maximize their potential," she says.
A combination of short- and long-term case management coupled with an intensive disease management program has paid off for CIGNA Healthcare.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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