Medicare disease management program reduces amputations and spending

Face-to-face sessions are a cornerstone of program’s success

An intensive face-to-face care management program for severely ill Medicare patients with advanced congestive heart failure and/or complex diabetes has paid off for XLHealth, a Baltimore-based disease management firm. The company has reduced spending by as much as 26% after 24 months of intervention for private HMO patients and has reduced lower limb amputations by more than 60%.

The program provides face-to-face care management sessions with patients and person-to-person pharmaceutical consultations when needed. In addition, the nurse care managers meet with physicians and their clinical staffs to discuss the patient’s care plan.

"When the company was created, there were some disease management programs out there, and all used telephonic call center models. We felt that face-to-face contact with a nurse care manager and perhaps a pharmacist, in some cases, would be more effective for the Medicare patients who are at risk for increased health care needs and higher health care costs," says Paul Serini, executive vice president of XLHealth.

XLHealth was awarded the Disease Management Association of America’s Recognizing Excellence Award for the Best Disease Management Program: Medicare. In addition, the company has been chosen by the Centers for Medicare & Medicaid Services (CMS) to conduct a three-year demonstration project for 10,000 Texas fee-for-service Medicare patients with advanced congestive heart failure and/or complex diabetes with a cardiac inpatient event and complications in the lower extremities.

The company predicts that the 10,000 patients in the program will see in aggregate a 50% reduction in amputations and other serious diabetes foot complications and a 50% decline in heart failure events. Patients enrolled in the program represent the sickest 4% to 5% of the Medicare population, Serini adds.

"Medicare fee-for-service patients with chronic illnesses are different from the type of patients who enroll in a Medicare health plan. They’re not financially motivated, are slower to make decisions, and rely a lot on the advice of family members and friends," he says.

The patients picked for the program are those who are at risk for consuming the greatest amount of health care resources.

"Most are socially isolated and clinically depressed with little social support. They don’t want to bother the doctor. They can’t drive to the podiatrist, and they don’t want to call a taxi because it costs too much," he says.

Serini credits the face-to-face interventions for the dramatic reduction in amputations and health care costs.

For instance, many of these patients in Medicare programs have foot ulcers that they treat with over-the-counter medication, waiting until it becomes so severe that sepsis has set in or the patient is facing an amputation.

"We have found that when we call the patients before a home visit, about half of those who have ulcerated wounds say that their feet are fine. If they have neuropathy, they can’t feel their feet. Many are obese and can’t see their feet. They may live alone and not know they have problems or they may not know it’s serious," he says.

Home assessment helps identify any problems that the patient has before they exacerbate into a costly health care experience, he says.

"Our medical experts tell us that almost 95% of amputations are avoidable from a clinical perspective if we intervene with the patient early enough," he says.

When XLHealth starts a program, the company examines the entire patient population and uses administrative, pharmacy, and laboratory data to stratify the population into five levels.

The nurse care managers call each patient and conduct a 15-20 minute telephone assessment. Depending on patients’ level of severity, the nurse care manager asks if they would be willing to participate in a 45-minute face-to-face assessment.

The assessment may be conducted at the patient’s home, at a special area set aside for XLHealth at a local pharmacy, at a physician’s office, a senior citizens center, or another location that is comfortable for the patient.

During the assessment, the nurse care manager collects clinical data, checking diabetic patients for neuropathy and hot spots, conducts a depression screening, reviews all the patient’s medications, and in some cases collects blood samples. "Based on 500 or more data points that we collect, the patient is restratified and the information is used to create a patient care plan that supports the physician’s plan," Serini says.

The comprehensive care plan, created by XLHealth’s proprietary computer software system, was developed with input from a medical advisory panel of cardiologists and endocrinologists who reviewed the proposed care plans.

When the initial care plan is developed, the nurse care manager goes to the physician office and meets with the physician and clinical staff to walk them through the report, ensuring that the plan supports the physician’s efforts and telling them about frequency and content of follow-up reports.

"The packages that are given to the physicians were developed over a period of four years by asking physician groups what information they want and what they want the reports to look like. They are very physician-friendly and helpful," Serini says, adding that the disease management company gets a 96% approval rating among physicians.

The patient also gets a copy of the care plan and a follow-up telephone call from the care manager.

Recommendations in the care plan are flagged in the company’s computer system until they are followed.

For instance, if a patient has a history of hypertension and is not taking an ACE inhibitor, the physician receives a report suggesting that an ACE inhibitor might be recommended for the patient, and the nurse care manager follows up with the patient, reminding him or her to speak to the physician about the drug.

"These two tasks are scheduled by the system, and they remain on the schedule until they are completed," he says.

Patients at the highest risk categories receive the most interventions. There is no set number of interventions per patient. Instead, they are event-driven.

For instance, the nurse care manager may suggest that a patient with foot problems go to a podiatrist and may arrange for transportation if needed. Two weeks after the podiatrist visit, the nurse care manager visits the patient to review what happened during the visit and to make sure the patient truly understands home foot care and foot issues.

"We are happy to pay for the follow-up because amputation can affect a patient negatively and it is expensive and it is always effective to have the care manager reinforce what the doctor told the patient," Serini says.

In another case, if a patient is on multiple medications and demonstrates a low level of understanding of why he or she is taking them, the patient is referred to a local pharmacist, who works with XLHealth. The pharmacist spends about an hour with the patient, doing a comprehensive medication review and educating the patient on what each drug does and why it is important to take it as prescribed.

The pharmacist has access to the complete clinical records and in some cases may discuss the patient’s prescriptions with the physicians.

The pharmacist intervention has helped alleviate poly-pharmaceutical issues with many of the patients, he says.

"A lot of these patients are medically homeless, and their care is provided by a cardiologist, an endocrinologist, an internist, a hospitalist, and an emergency department physician. A patient may have a tremendous number of prescriptions. Working with the pharmacist, we routinely are able to stabilize the patient’s medication by cutting out duplicates or medications that are incompatible," he says.

Most CMs work out of their homes

The program in each community is staffed by several levels of nurses: a program manager who is in charge of a group of nurses in a metropolitan area; six to 10 nurse case managers; a panel of per diem nurses who work for local home care agencies and are called on to manage various patient demands; nurse coaches who work with patients by telephone; and inpatient nurses who go to local hospitals and oversee the care of patients in the hospital who are not being managed by a health plan case manager.

"If a health plan has a robust case management program, the need is limited, but Medicare fee-for-service patients often don’t have a case manager working with them except for the hospital case manager," he says.

When the program begins in a community, the nursing program manager meets with the large medical practices to describe what will happen.

Most of the nurse care managers work out of their home. They begin the day by logging onto XLHealth’s web-based system and retrieving their work plan for the day, then prioritizing the patient visits. They go to the central office for staffing meetings and educational sessions.

Many of the company’s call center nurses also work in their homes.

"This gives us great flexibility to be able to ramp up and ramp down when we need to," Serini says.

The first patients for the Medicare Disease Management Demonstration project were enrolled in April, with clinical interventions starting in June. About 8,000 of the 10,000 enrollees have received home assessments.

In addition to the Medicare Disease Management Demonstration project, the firm has collaborated with physicians and their Medicare HMO patients enrolled with major health plans.

Serini emphasized that the program is most effective for patients who are in a Medicare risk plan and might not be effective for the general population.

"Our program was designed for people who are seriously ill and are in a Medicare risk plan. It works extraordinarily well for this population, but it would not be a good program for a commercial health plan. A 45-year-old working diabetic has a very different profile," he says.

The company provides person-to-person interactions for between 30% and 90% of its enrollees, depending on the severity of the conditions of the particular population. The interventions are supplemented with telephone calls and packets of educational materials.

"We generally see about 70% of our Medicare patient population face-to-face. In a commercial program, if we are managing all the patients with diabetes or heart failure, many would not need face-to-face interventions," he says.