Health program saves $1.70 for every dollar
Inpatient admissions down, member satisfaction up
A health management plan for members with chronic conditions has generated a 1.7-to-1 return on investment and glowing responses to member satisfaction surveys for Health Alliance Plan (HAP).
Health Alliance Plan began the HAP HealthTrack program in August 2004 with a program for members with heart failure and expanded it to include other chronic conditions after the heart failure component showed a decrease in hospitalization and an increase in recommended care. For instance, from 2003 to 2005, the number of inpatient admissions among HAP members with congestive heart failure declined by 65%. Use of ACE inhibitors among members with heart failure increased from 38% prior to the program's implementation to 78% in 2005. The percentage of members with LDL cholesterol levels below 100 mg/dt increased from 61% in 2003 to 70% in 2005.
"In addition to the financial gains and improvement in member health, this program has enhanced member satisfaction. This year, we've had about close to a 70% return rate on our surveys. We have evaluated the first 117 surveys returned and 100% of members who talked to a case manager reported being satisfied or very satisfied," says Richard Precord, MSW, director of clinical care management for the Detroit-based health plan.
Members at high risk for hospitalization or complications from the disease work with an RN case manager, and, if indicated, a behavioral specialist or pharmacist, who helps them learn to self-manage their conditions.
"We have developed a member-centric chronic care registry rather than a disease-specific registry. We approach our members holistically, rather than from the standpoint of a disease," Precord says.
The case managers are cross-trained to work with members with all of the conditions in the program and attend regular in-services on the various conditions. They can call on a certified diabetic educator if needed when they work with members with diabetes.
"We have a high prevalence of comorbidities. For instance, many of our members with heart failure also have diabetes. There aren't very many members who have just one condition. We look at all the members' needs and work with them on all conditions," Precord says.
Members are identified for the program by a variety of methods. The health plan automatically analyzes medical claims, pharmacy claims, and laboratory claims and values every month to identify members with chronic conditions. The computerized system also looks for gaps in care that may indicate that a member's disease is not being well-managed. For instance, the program flags members with diabetes who have not had regular hemoglobin A1c tests as well as those whose test results are outside the normal range.
The enrollment packet sent to new members includes information about the program along with the insurer's web site and a telephone number to call for more information. If the data show that new members are not managing their chronic disease well or have not had the recommended tests and procedures, they are referred to the program for appropriate intervention.
"Our data system also identifies members who were admitted to the hospital with a chronic disease or who have had a coronary event and been hospitalized as soon as they are discharged so that a case manager can call them. We also get referrals from physicians and other providers," Precord says.
The names of members who are identified with chronic illnesses and gaps are forwarded to an enrollment center where the staff make outbound calls to members to discuss the program and schedule them for a telephone appointment with a case manager.
"There are health risk indicators for each condition that prompts a telephone call," Precord says. For instance, a member who has a high LDL cholesterol level or someone who has made a visit to the emergency room is referred to case management.
The case managers have the member's health profile, medication, labs, and utilization data at their fingertips when they call the members. The case manager completes an extensive assessment over the telephone and, based on the assessment and other information, the case manager identifies goals and works with members to set priorities, Precord says.
"In the past, the case managers would get a member's name and number and then call the doctor's office to obtain clinical information. We have put together a methodology we use to prioritize members. They are risk stratified before the nurse calls them and the relevant clinical data are readily available to the nurse. It's a much more efficient way of doing things," he says.
Case managers frequently contact members over the first three months, then taper off the calls when the members begin to better manager their condition. Members work with the same case managers on managing their conditions.
"Many of these members are trying to manage multiple conditions, which can be very overwhelming. The case managers work with them on getting the conditions under control and eliminating barriers to appropriate care," he says.
HAP's case managers go through training on motivational interviewing and behavioral changes so they can more effectively engage members and facilitate healthy behavioral changes.
"Helping members manage chronic diseases is not as simple as just calling them and telling them what to do. Case managers need to find out what motivates people to change," he says.
Since there is a high prevelance of depression among people with chronic conditions, the disease management case managers may co-manage members with the behavioral health team when appropriate.
HAP's program promotes self-management of chronic diseases. During the early weeks members are in the program, case managers work with them to develop action plans and to set health goals.
The case managers 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 case manager can refer a member to the pharmacist if the member with asthma is using his rescue medicine too much or if a diabetic has questions about getting his LDL cholesterol under control.
The clinical pharmacists talk with the members and educate them on how and when to take their medication. They may contact the members' physicians to discuss medication or dosage changes.
Members with chronic obstructive pulmonary disease, heart failure, and diabetes who are at high risk for hospitalization are eligible for HAP's telemonitoring program.
Members in the program receive a small appliance that plugs into the telephone line. The appliance beeps every morning to remind members that they need to answer a series of questions. For instance, members 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 members whose answers indicate health problems.
"The system helps us identify people early when they have difficulties and gives us the opportunity to intervene. The member may be scheduled for the next phone call from a case manager next week but if there are signs of a deteriorating condition today, the case manager can take action to help them get needed care or avoid a potential visit to the emergency room or a hospitalization," he says.
Case managers in the program work hand-in-hand with physicians to help the members learn to manage their condition.
"We emphasize to the members that we 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 member is identified for case management, HAP sends a letter to the physician with details about the member's condition and the goals the member and case manager have set.
The plan sends physicians regular updates as the members 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.