Health management program promotes self-management

Health Alliance Plan (HAP), a Detroit-based health plan, promotes self-management of chronic diseases. During the early weeks members are in the program, staff work with them to develop action plans and to set health goals.

The staff call on HAP's clinical pharmacists for a consultation if a member isn't taking their medication or has questions about the medication. For instance, the staff can make a referral to the pharmacist if an asthmatic is using his rescue medicine too much or if a diabetic has questions about getting his LDL cholesterol under control.

The clinical pharmacists educate them on how and when to take their medication. The pharmacists may contact their physicians to discuss medication or dosage changes.

Those with chronic obstructive pulmonary disease, heart failure, and diabetes who are at high risk for hospitalization are eligible for HAP's telemonitoring program. They receive a small appliance that plugs into the telephone line. The appliance beeps every morning to remind them that they need to answer a series of questions. For instance, those with heart failure are asked to weigh themselves and answer a series of questions that assess their symptom knowledge and behavior patterns.

The system automatically flags those whose answers indicate health problems.

The system helps HAP identify people early when they have difficulties and gives staff the opportunity to intervene, says Richard Precord, MSW, director of clinical care management. They may be scheduled for the next phone call from a staff person next week, but there may be signs of a deteriorating condition today, Precord says. Staff can take action to help them get needed care or avoid a potential visit to the emergency department or hospitalization, he says.

Staff work hand-in-hand with physicians to teach them to manage their condition. They emphasize that they are helping them follow the treatment plan from their physician, Precord says.

The health plan sends provider bulletins and newsletters to physicians to let them know that the program is available to support their plan of care. When a patient is identified as needing their services, HAP sends a letter to the physician with details about the patient's condition and the goals the patient and the staff have set. The plan sends physicians regular updates as the patients work toward meeting the goals.

"If something urgent arises, the nurses alert the members' physicians by telephone and work with them to get the condition under control," he says.