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Integrated program takes proactive approach to care
Care coordinators link members with local resources
When members of Blue Cross Blue Shield of Florida are seriously ill, injured, facing surgery, or need help negotiating the health care system, their care is managed by a care coordinator located in their region.
The Jacksonville-based insurer consolidated its utilization management and case management functions and added member outreach, discharge planning, and cross-training registered nurses to handle all of the functions.
Members now have a single point of contact — locally based care coordinators who are registered nurses and who can support them in making decisions about their health care, help them understand the alternatives available under their benefit, assist them in managing their health care dollars effectively, and promote compliance with their treatment plan.
Members happy with single-point contact
Since the company rolled out its Regional Care Coordination on Feb. 14, 2006, member satisfaction has soared, according to Claudia Castro, RN, CHCQM, FAIHQ, senior manager of regional care coordination for the northern region.
Recently, the care coordination program received a score of 4.82 out of a possible 5 points on the health plan's member satisfaction survey.
"With the complexity of today's health care system, members are very appreciative that someone is there to help them," she says.
The enhanced model provides a single point of contact for members, eliminating handoffs and the need for members to talk to multiple individuals as they move through the continuum of care.
"Now a single care coordinator handles member outreach, concurrent review, discharge planning, member education, case management, and member satisfaction. Our members have a single point of contact and one person they can call when they have questions or issues. There is also the single point of contact for facilities and physician providers for that member as well," she says.
Before the health plan went live with its integrative care coordination program, the utilization review nurses and the case managers went through an intensive skills assessment process and were cross-trained to perform all components of the job.
The insurer has three regional care coordination offices with field offices located throughout the state that help the company provide care and options that are tailored to the regional differences and different cultures located in various areas of Florida.
The care coordinators in the local markets are knowledgeable about the local health care delivery system as well as community resources that the members might need, Castro says.
"Care coordinators who are familiar with the local market can provide enhanced assistance for members as they navigate through the entire health care spectrum. They are informed about our participating providers and any type of service the member may need, whether it's acute inpatient care, home health, or durable medical equipment," she says.
The fact that the care coordinators have established a relationship with local providers makes it easier to facilitate care for the member, she adds.
Members are referred for care coordination by all internal departments at Blue Cross and Blue Shield of Florida — facility providers, physicians, ancillary network providers, and self-referral.
Any member with complex needs is referred for care coordination. For instance if a member is having difficulty getting an appointment with a specialist or is having problems getting precertified for a certain test or procedure, the care coordinator can review the provider network and options for the member and, if necessary, ask the medical director to assist in bridging any access to care issues.
"We take a personalized approach based on the member's need. There is no cookie-cutter plan for care coordination. Someone may be in care coordination for one or two months or through the entire continuum of care over a long period of time," she says.
For instance, a member might have a complex infection or serious injury that requires intensive wound care and may result in care from providers from the acute inpatient setting to a skilled nursing facility, then home care, and then outpatient care.
"We continue to actively participate in the member's care throughout the episode so we can ensure that the member is getting the right services in the right setting at the appropriate time and is moving to the next level of care when appropriate. At the same time, we make sure that the member is aware of his or her responsibilities and options based on their benefit structure," she says.
The arrangement results in increased efficiency because the care coordinators are already familiar with the members when they call and they don't have to spend a lot of time reading someone else's notes, allowing them more time to address the needs of the members, she adds.
The company takes a proactive approach to reach out to members who may be facing surgery or another health care event by initiating calls to the member as soon as the provider requests precertification for treatment.
As soon as a care coordinator is notified that members are scheduled for orthopedic surgery, he or she calls the member, conducts an assessment, and starts to develop the discharge plan before the surgery takes place.
Proactive approach to discharge planning
The proactive approach to discharge planning is a benefit for members who have to assume responsibility for part of the cost of their health care, Castro points out.
"Our care coordinators prepare the members for what to expect depending on their benefit structure, such as what their covered benefits are and what they will have to pay out of pocket. They discuss discharge planning options, such as rehabilitation, discharge to a skilled facility, or discharge to home," she says.
In the case of members who are having orthopedic surgery, such as total knee replacement, the care coordinators educate them about a home exercise program they can do in advance of the surgery to facilitate the recovery process.
The care coordinators call members after discharge to make sure everything is going well and that their discharge needs have been met and that they have made an appointment for a follow-up visit with their physician. They answer any questions or concerns the members have and refer them to a physician if the situation warrants it.
"This is a proactive step to help the members avoid rehospitalization. If things are not going well, the case manager can assist the member getting the care they need," she says.
If the member is discharged to a post-acute rehabilitation center, the care coordinators follow them while they are in the facility and after they are discharged to home to make sure their needs are being met. When a member is home from the hospital and stable, the care coordinator closes out the active part of care coordination and follows up with a member satisfaction survey.
The health plan is rolling out the next wave of member outreach to members who have been precertified for other surgical procedures.
When hospitals notify the health plan that a member has been admitted, within a day after admission, the care coordinator assigned to that facility is aware the member has been hospitalized. The care coordinators then make outreach calls while the member is still in the hospital, if he or she meets the outreach criteria.
"We triage our members who are hospitalized to ensure that we reach the people who can most benefit from an intervention," she says.
For instance, a healthy 19-year-old member with appendicitis who is moving through the continuum of care on schedule is not likely to receive an outreach call.
On the other hand, a 19-year-old with appendicitis who stays in the hospital beyond the normal two-day stay will receive an outreach call.
"The care coordinator will call to determine what is keeping the member in the hospital. It may be that there is a comorbidity, such as diabetes, or a ruptured appendix with a level of infection that may require antibiotic therapy after discharge," she says.
When a hospitalized member has a chronic disease, the care coordinator takes the opportunity to link the members with the BluePrint for Health disease management program if the member is not already enrolled.
The care coordinators work with the discharge planners at the hospital to complete the discharge plan in advance of the discharge day. The members are active participants in creating the discharge plan and are aware up front of what their financial obligations will be, depending on the post-acute options they choose.
"In the previous model, concurrent review and case management were handled by separate nurses. The discharge planning was largely relied on as a facility obligation. We've taken a lot of the burden off the facility. They're not spinning their wheels creating a discharge plan and finding on discharge that the patient does not have that benefit," she says.
The care coordinators work with other community resource local providers to ensure that all of the members' health care needs are met.
"It's a collaborative process. We work with all providers, whether it's a surgical coordinator, a physician, a hospital, a skilled nursing facility, rehabilitation facility, home health agency, durable medical equipment provider, or infusion care company," she says.