Program helps Medicare members stay healthy

Holistic approach combines management

Medicare Advantage plan members are getting help managing their chronic conditions through Sterling Life Insurance's care coordination program that combines disease management and case management.

"We included the care coordination program when we developed the Medicare Advantage plan as a way to help us attain our goal of promoting quality care," says Sandy Harnden-Warwick, PT, MPT, GCS, CCM, manager of medical management for Sterling Life Insurance.

Sterling was the first company to offer seniors a private fee-for-service Medicare Advantage option. One product offered by the Bellingham, WA-based insurer covers members in 33 states while another product has members in 42 states.

Sterling encourages voluntary participation in the company's telephonic care coordination program, which provides program services to members with chronic conditions and those who need assistance during major acute-care episodes, including strokes, heart attacks, or surgery.

The program offers a combination of case management and/or disease management depending on the enrollees' needs.

"We take a holistic approach to case management and disease management. Members in the Medicare population often have multiple comorbid conditions, yet each individual is unique with special problems and concerns," says Joanne Allison, RN, CCM, PA-C, supervisor of care coordination.

The care coordinators are all registered nurses, with experience in multiple areas in the case management field and an average of 26 years' experience.

"What is unique about our program is that we don't have nurses who do case management and others who handle disease management and transfer the member from one nurse to the next. The reason our program works so well is the continuity of care and the trusting relationship that develops between the enrollee and the nurse," Allison adds.

24-hour advice line

A 24-hour-a-day, seven-day-a-week nurse advice line is another key component of the program.

"Twenty-four hour access is important for this population because in many cases, their support structure may be on the decline and their resources limited. Many seniors are reluctant to call their children because they don't want to bother them. It's important for enrollees to have someone they can call with questions," Harnden-Warwick says.

The insurer identifies prospective members in a variety of ways including voluntary health risk assessments completed at enrollment, hospital admissions, claims data, and referrals from the nurse advice line.

Potential referrals are reviewed by the plan's medical intake RN. If a member is eligible, he or she receives a mailing or a telephone call explaining the program.

"It's a voluntary program and even if the enrollee isn't interested in the beginning, they often remember the program and contact us. Self-referral is one of our primary sources of referrals," Allison says.

When the member enrolls and gives his or her consent to participate, the case is assigned to a nurse care coordinator who conducts an in-depth assessment that includes the patient's medical condition and social issues. The case manager talks with the member to identify what issues the enrollee wants to tackle first.

The nurses have been trained in motivational interviewing techniques and how to assess readiness to change.

"We help the patients move from where they are to the goals we ultimately want them to achieve. We let them direct the process as much as possible," she says.

For instance, if a patient has always been a smoker and says he has no intention of quitting, the case manager will work on other goals.

"We give them choices and offer directions. They may not know what they want to talk about today but they react better when they have a choice and control over the conversation," Allison says.

The nurses are well-versed in working with patients with multiple conditions. They have access to web sites and other materials as well as trading ideas with each other.

Members with diabetes have the opportunity to participate in a focused health coaching program that includes specific educational modules. The care coordinators working with the diabetic population call their clients every two weeks for the first eight weeks and monthly after that and work with them to keep the condition under control.

"They get the same care management services as the other enrollees in addition to the diabetes focus," Allison says.

The case managers give members the education they need to talk to their physician and encourage them to address their concerns about medication and other issues with their physicians.

"We are here to support the physician's plan of care, not to tell the physicians how to do their job. We give the member the educational background they need to self-manage their conditions," Harnden-Warwick says.

The care coordinators work closely with the local agencies on aging, finding out resources that are available in the community, such as Meals on Wheels or organizations that loan durable medical equipment to seniors.

The case managers ask questions to determine home safety, what kind of support the enrollees have in the home or in the community, and conduct a depression assessment. The assessment gives the care coordinators an indication if a member may need help with household chores or meal preparation or may need transportation assistance or help from other community programs.

"Members share what they don't have during the interviewing process. Because of their clinical knowledge, our case managers know what the seniors need and take it from there," Harnden-Warwick says.

"We take pride in the fact that we have identified community agencies that can help our members. We think of ourselves as private detectives. Our nurses love to find new resources and share them with their colleagues," she says.

In many cases, the care coordinators spend time addressing the member's lifestyle and social service needs before they begin helping the members manage their chronic conditions.

"Each person has individual needs and concerns and some members are having difficulty with day-to-day survival. Until their initial concerns about basic needs, such as food and safety, are addressed, we can't address other areas," Harnden-Warwick says.