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Multi-pronged plan helps members with chronic illness
Interventions depend on the severity of disease
Health Plan of Nevada Inc. takes a multi-pronged approach to managing the care and services of its chronically ill members throughout the continuum of care.
Depending on the severity of their condition, members' care and services may be coordinated by an RN health coach or a case manager. A home health nurse at one of Health Plan of Nevada's sister companies, Family Health Care Services, may become involved when the member requires regular monitoring of his or her condition using an in-home telemonitoring device.
Health Plan of Nevada is a wholly owned subsidiary of Sierra Health Services, a Las Vegas-based diversified health services company. Other Sierra Health subsidiaries include Southwest Medical Associates, the largest multi-specialty medical group in Nevada with a staff of 250 staff doctors who work in 14 clinical locations.
Health Plan of Nevada's health management program focuses on four chronic conditions — chronic obstructive pulmonary disease, congestive heart failure, diabetes, and pediatric asthma.
The program was developed in partnership with Southwest Medical Associates, which many members choose for primary care providers.
The health management program has resulted in an increased number of members who receive the recommended tests and procedures for their chronic diseases, reports Deborah Wheeler, MSPH, director of quality improvement.
For instance, the percentage of members with diabetes who had hemoglobin A1c tests increased from 72.8% in 2003 to 83.5% in 2006. During the same time period, the proportion of individuals with diabetes who received LDL cholesterol tests rose from 75.2% to 91.5% and those who received screenings for kidney disease increased from 49% to 62%.
When members are identified for the program, they are stratified into low, moderate, and high-risk groups, based on their history of inpatient hospitalizations, emergency department and outpatient visits, and/or laboratory test results, according to Wheeler.
Depending on their level of risk, the members receive interventions designed to help them get their condition under control and avoid developing complications or being hospitalized.
All members receive disease-specific materials when they are identified for the program and receive follow-up postcards reminding them of recommended tests or procedures such as eye examinations for members with diabetes and flu shots for all members in the program.
Members at high and moderate risk work with health coaches who educate the members on their disease, make sure they receive recommended tests and procedures, and work with them to help them follow their physician's treatment plan.
The RN health coaches are supported by non-clinical staff who make initial contact with the members and schedule them for a phone call from the health coach, helping maximize the time of the health coaches, Wheeler says.
When the health coaches make their first telephone calls to the members, they conduct a health assessment and review the member's health issues. They encourage the members to see their primary care physician if they have not had the recommended disease-specific tests and examinations, she adds.
The role of the health coaches is to support the treatment plan of the providers, to make sure the members remain compliant with their medication regimen, and to schedule appointments for recommended care. The frequency of the telephone calls depends on the member's risk level.
The health coaches work to develop a relationship on an ongoing basis and typically work with the same member as long as he or she is in the program.
"The health coaches work with the primary care physician to encourage the member to self-manage his or her condition. They help the physician identify other issues with the members and contact the physician if they feel a member may be experiencing an acute problem," Wheeler adds.
The health plan's electronic case management software application allows the health coaches to communicate instantly with the home health agency, Southwest Medical Associates, Health Plan of Nevada's case management department, and other services, and to transfer members seamlessly between various components of the program.
"This helps coordinate care between the services and the departments. Our system allows for referrals to go back and forth. Members who are in case management may be referred back to a health coach when they become stable or refer them to the home health program if they need to be closely managed," says Dana Zuckerman, RN, BSN, MA, CCM, assistant vice president for utilization management and case management.
For instance, if the health coaches determine that members have complex issues, acute issues, and/or needs beyond monitoring their condition, they are referred electronically to case management. This includes members who need durable medical equipment or help getting access to social services.
Once the acute issues are stabilized and the member has been set up with equipment or linked to community social services, the case manager transfers him or her back to the health coach.
The case managers coordinate the care for members with major trauma after an accident — from acute care through rehabilitation and outpatient rehabilitation. They manage the care of premature infants, high-risk obstetric patients, members with cancers, and those who are receiving care outside the service area.
"The case managers coordinate care for people who need a lot of services including those with complex conditions who see multiple physicians. Members in case management represent about 1% of the population and they are the ones at highest risk," Wheeler says.
When a member is referred to case management, the case manager conducts a complete assessment.
"We are not just looking at diabetes or heart failure. We take a holistic approach and look at the entire person and everything that is happening with them," Zuckerman says.
The case managers develop a plan of care and take care of what the member needs right then.
If their plan of care is related to a specific disease and the member requires no other interventions, he or she is referred to health management and a health coach.
If the member has comorbidities or other issues or is going outside the service area for care, the case manager coordinates the care.
Most members of Health Plan of Nevada who need organ transplants must go out of state for the service.
For instance, if a member with diabetes needs a kidney transplant, the health plan case manager coordinates the appointments for laboratory procedures, X-rays, and treatment at the hospital where the transplant will take place and follows the members after the surgery to make sure they get everything they need.
Some members with congestive heart failure are eligible for a telemonitoring program offered by the health plan's affiliated home health company.
When a member is eligible, a home health nurse makes a home visit, evaluates the home environment for safety, and determines if the member would be a good candidate for telemonitoring.
If so, they receive a device in their home that they use to input their weight, vital signs, and health status. The home health nurses monitor the results and call in the member's physicians if they see a decline in health status.
Sierra Health Services' computer system is set up so that components that receive a referral can instantly tell if a member's care is already being managed by another component.
For instance, if a health coach receives a referral of a member who is at high risk for hospitalization for congestive heart failure, he or she can immediately determine if the member is already enrolled in another program, such as the home health remote telemonitoring program or Southwest Medical Associates' congestive heart failure clinic.
"If members are already being managed by other services, the health coaches don't duplicate the services," Wheeler says.
The health plan sends a quarterly profile to the members' primary care physicians showing which of their patients have or have not had disease-specific examinations, along with information on the frequency of hospital, outpatient, and emergency room visits for the condition.
The pediatric asthma program works much the same as the health coaching programs for other chronic diseases. The RN health coaches work with the parents of children less than 18 who have asthma and help them learn to manage their children's disease.
The parents receive educational materials and information about how to participate in Sierra's health education and wellness classes on childhood asthma.