Health plan reduces high-risk conditions
Members engaged in medical management
A proactive approach to engage at-risk members before they have an adverse medical event is paying off for CareFirst BlueCross and Blue Shield, a Baltimore-based health plan.
The initiative utilizes a health risk assessment to refer members to medical management programs based on their answers. When the health plan analyzed the scores of members who took the health assessment two years in a row, the percentage of people who were at high risk dropped from 37% to 16% in the second year, according to Richard Safeer, MD, medical director of preventative medicine for the plan. One employer group has had three years of experience with the health assessment program. Overall wellness scores have increased and the average number of risks have dropped every year.
Engaging At-Risk Populations received a gold award from URAC, (formerly known as the Utilization Review Accreditation Commission), the independent healthcare accreditation organization, based in Washington, DC.
"The health assessments help us identify people who could benefit from interventions earlier, before they have a major illness of hospitalization, and engage them in our medical management programs," Safeer says. "We usually know about those who already are sick, but there are a lot of people out there who don't realize that they are at risk for an adverse healthcare event, or they realize it and don't know how to get help."
The assessment measures any health issue that places members at greater risk of an adverse event, such as high blood pressure, high cholesterol, lack of exercise, smoking, poor dietary habits, as well as conditions such as diabetes, heart failure, and asthma. All members who choose to take the health assessment receive a report with details on their health risks and what resources are available through the health plan. The report is available in an electronic format as well as paper, based on the choice of the member.
The health plan developed a proprietary algorithm that determines which program would be best suited to which individual, based on their answers to the health assessment, and refers them for lifestyle coaching, disease management, or case management. Depending on the results of the assessment, members with health risks are invited to use web-based health coaching tools or to receive telephonic coaching, disease management, or case management. "The interventions the member receives depends the person's stage of needing help with keeping their chronic conditions under control. The higher the member's risk, the more likely he or she is to receive a call offering telephonic support," Safeer says.
For example, if a woman answers that she is pregnant, she is invited to participate in the health plan's Great Beginnings, a case management program designed to help women through pregnancy to optimize the outcomes and the health of the baby.
The health assessment identifies members who have high intensity needs for their current health situations and could benefit from one-on-one case management. Examples include members who are going through rehabilitation after an automobile accident or people who are waiting for an organ transplant.
When members indicate they have diabetes or another chronic disease on the health assessment, a disease management case manager calls them and invites them to participate in the health plan's disease management program.
"Some of these individuals may have been picked up early in our data mining but did not engage with a case manager. After the health assessment, a case manager will reach out again and offer to help them navigate the health system," Safeer says.
For members with lower risks, CareFirst offers a dozen online coaching programs ranging from smoking cessation to healthy eating to taking care of your back. The program may be augmented by telephone coaches who work with individuals to help them make healthy lifestyle choices such as increasing the number of servings of fruits and vegetables and fiber in their diet. "We don't focus on weight because we believe that if people eat well and exercise, weight will fall in line," he says.
The health coaches ask members about the amount of fruits and vegetables they are eating and whether they are interested in changing their behavior. Based on their answer, the coaches can customize an online program and telephonic coaching. The health plan offers six different nutrition modules online.
"By moving people from a high-risk state to a lower risk, and by helping them navigate the healthcare system to get the care they need to manage their conditions, we help individuals get healthier and employers save on the coverage they provide," Safeer says.
A proactive approach to engage at-risk members before they have an adverse medical event is paying off for CareFirst BlueCross and Blue Shield, a Baltimore-based health plan.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content