System shares top 10 lessons learned
Success begins with senior management
The success of any new initiative often comes only after a painful period of trial and error. Lovelace Health Systems in Albuquerque, NM, is no exception. The large integrated system found that implementing its disease management programs became reality mainly because top brass bought into the concept, says Margaret J. Gunter, PhD, vice president and executive director of the Lovelace Clinic Foundation, a nonprofit research institute at Lovelace Health Systems.
Lovelace introduced its disease management efforts in 1993. The system first identified 30 conditions that accounted for more than 80% of its total costs and then selected nine of those for the initial Episodes of Care program, Gunter says. The nine included:
• pediatric asthma;
• diabetes;
• birth/prematurity prevention;
• low back pain;
• depression;
• coronary artery bypass surgery;
• stroke.
For disease management to work in integrated systems and managed care plans, early health risk appraisals are crucial, Gunter says. "The shorter the time between health risk appraisal and care management, the more proactive and cost-effective your programs will be. We risk profile all new members at time of enrollment and get them into case management for reduction of overall risk right from the start."
Gunter says Lovelace learned 10 vital lessons from its efforts to develop and implement its disease management programs:
1. Secure complete support from top managers. "Without support from your top management, you won’t get the resources you need to succeed," she says. "It helps to cite examples from other successful programs."
2. Create multidisciplinary teams. "We’ve made an effort not only to create multidisciplinary care teams but to involve all levels of folks in the programs," Gunter says. "For example, we’ve got our medical assistants helping diabetics remove their shoes and socks before the physician enters the exam room to help remind the physician to do a foot exam." (For more on Lovelace’s care teams, see box, p. 189.)
3. Recruit effective clinical champions. "Some-times the very best clinicians are not the best team players. We’re helping all our specialists and primary care physicians to learn to work as part of a care team."
4. Lobby for essential resources. "Get the resources you need upfront. Success takes substantial investment. Ask for case managers and integrated data systems. Without the right tools, you can’t succeed."
5. Seek a balance of outcomes. "Don’t focus on utilization changes alone," Gunter cautions. "Include both clinical outcomes and humanistic outcomes, such as patient satisfaction and patient functional status."
6. Emphasize patient-centered prevention. "We must empower our patients to care for themselves if disease management is going to work. We give our diabetes patients a card to carry in their pocket or wallet that reminds them when it’s time for their next foot or eye exam."
Empowering patients also requires that health systems reach out beyond their own borders and into the community, she says. "The pediatric asthma program has gone out to the schools to talk to the physical education teachers and school nurses about appropriate management of our asthma patients. We’re not going to be 100% successful in keeping kids out of the hospital for asthma unless we get the message about prevention and treatment into the schools. We can’t have the PE teacher telling kids to go out and run a mile because it’s good for their asthma. We can’t have the school nurse locking up the inhaler because she doesn’t understand the importance of its use."
7. Clinicians and data analysts must communicate. "We found out that when our data analysts don’t have input from our clinicians, we get really strange numbers."
8. Invest in good electronic data systems. "A good electronic data system means that you don’t have to rely on chart reviews to get the full range of outcomes you want to measure."
For example, for the Birth Episodes of Care program, women sit at a computer terminal and complete a risk appraisal on-line at the time of their first prenatal visit. Women repeat the on- line appraisal at 26 weeks and 32 weeks. If the appraisal identifies any risk factors for prema-ture or low birth weight delivery, the patient is referred to the perinatal case manager.
9. Provide physicians with data feedback. "Many physicians are uncomfortable with data feedback. They’re afraid there will be some punitive action if their outcomes compare unfavorably with other physicians," Gunter explains. "You have to keep assuring physicians that the data are confidential and that you are sharing it only with them."
Lovelace reports outcomes to its providers on a quarterly basis. "We give physicians comparisons of how they are doing. We tell them which of their patients has had an admission. We try to focus on information that will help physicians perform better in their daily practice."
10. Celebrate your own successes. "It’s not enough to share your success with employers for marketing purposes," Gunter says. "You must also share your good news with your own physicians and nurse case managers. Let them know how proud they should be. Make sure your own marketplace and your own people know about your successes."
Lovelace has had some successes to share since the Episodes of Care programs were introduced in 1993. For example, the Birth Episode of Care has reduced the system’s cesarean rate from 23% to 14%. In addition, Lovelace’s vaginal birth after cesarean rate has risen from roughly 50% to 58%.
The success of all the system’s Episodes of Care programs also has paid off for Lovelace in the marketplace. "Consumers have expectations from us to be accountable for cost and quality. We had to demonstrate cost-effectiveness, clinical quality, and patient satisfaction," Gunter says. Since Lovelace has started sharing the success of the Episodes of Care programs with its community, the system’s enrollment has risen from 140,000 to about 200,000. "Employers are simply impressed with our data."
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