Multidisciplinary team guides proactive model
Goals include increased efficiency and effectiveness
The team that developed Anthem Blue Cross and Blue Shield’s proactive case management project had four goals in minds: adherence to evidence-based care and clinical guidelines; consistent application of best practices in the case management process; increased case management efficiency and effectiveness; and preventing targeted members from falling through the cracks.
"Our vision of proactive case management was a system that would be characterized by careful targeting and systematic identification of members. We felt it was important to initiate direct and continued contact with members, a major shift away from reacting to requests for authorization and hospitalization," says Alena M. Baquet-Simpson, MD, medical director, state of Ohio, Anthem Blue Cross and Blue Shield (BCBS) Midwest.
The project was designed by a cross-functional team that included all of the insurer’s internal stakeholders.
The development team had about 20 members, including the medical director, utilization manager, case managers at the corporate level, disease state management managers, and representatives from contracting, actuarial, health improvement analysis, legal, pharmacy, sales, provider relations, public relations, marketing, and quality improvement.
The team began by setting out what the project should accomplish, the scope of the project, principals to guide the design, and outcome measures. A keystone of the plan was making sure all the key stakeholders were involved in the case-management process. This included members, their families, physicians, and other providers.
"We wanted to be characterized by a coordinated and planned set of interventions driven by a case management plan based on established guidelines and benchmarks and that covered the full care continuum," Baquet-Simpson says.
Other parts of the plan included adding benefits for members by helping them navigate the health care system, regular measurement and analysis, and reporting of outcomes and results.
The first discussions about the program began in early 2001. The first members were enrolled in October 2001.
"The key is planning. You’re got to have good planning and development," says Mary Beth Newman, MSN, BC, A-CCC, senior project manager for case management at Anthem BCBS Midwest in Mason, OH.
The team used the data from their own system and research data, including two Institute of Medicine Reports on improving quality in the health care system to determine which conditions to include.1
"The Institute of Medicine has recommended conditions they feel should be managed to improve the health care system. In addition, clinicians who were project team members suggested conditions where we could make an impact," Baquet-Simpson says.
Reference
1. Institute of Medicine. To Err is Human: Building a Safer Health System; Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC. For more information on these reports, see web site: www4.nationalacademies.org.
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