Proprietary formula targets members likely to benefit
Benefits include follow-up, monitoring
Members who participate in Anthem Blue Cross and Blue Shield’s proactive case management pilot project were selected by a proprietary formula developed by a team of clinicians working with the health improvement-analysis department.
When the formula was applied to nearly 800,000 members, the result was to identify about 4,000 members who could benefit from intense case management.
In the first six months of the program, nearly 500 members enrolled in the pilot project.
Once members are identified, the next order of business is a comprehensive educational process to make sure the members have knowledge of their disease, that they understand nationally established guidelines for that condition, and that recommended therapy takes place.
For instance, diabetics are educated to know when they should get their eyes examined so they can initiate the services.
"It’s a new role for a member. In the past, they’ve been in a passive role. Now we want them to take an active role in managing their health," says Mary Beth Newman, MSN, BC, A-CCC, senior project manager for case management at Anthem BCBS Midwest in Mason, OH.
The case managers work with the targeted members to educate them and to give them the confidence they need to negotiate the health care system to get their needs addressed.
For instance, if a case manager finds that a member with diabetes does not clearly understand his or her diet or medication, the case manager can point out the benefits of diabetes education and help him or her get the services.
"The member might not realize these things on their own. We want to help them take full advantage of the benefits they have," Newman says.
A big benefit to the new approach is follow-up and monitoring.
"The case managers don’t just identify the needs and suggest to the members how to obtain service. They follow up and make sure the recommended tests or treatment has been done. If there are barriers, the case managers help them overcome it," Newman says.
Once a member is identified, the case manager uses risk-stratification criteria for each chronic condition to determine what interventions will take place and how frequently.
The case managers have the option of contacting the members more frequently than the minimum follow-up standards require.
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