Telephonic, face-to-face interventions help seniors

Special Needs plan focuses on four chronic diseases

Chronically ill Medicare beneficiaries are learning to keep their disease under control through Care Improvement Plus's "Special Needs" Medicare Advantage plan that includes telephonic disease management and face-to-face meetings with a nurse case manager.

The program provides individual disease management and case management for seniors in Maryland, Georgia, South Carolina, Missouri, Arkansas, and Texas, who have diabetes, heart failure, chronic obstructive pulmonary disease, and/or end-stage renal disease.

Medicare beneficiaries with one or more of those chronic illnesses are eligible to enroll in the program, says Harry Leider, MD, MBA, chief medical officer for XLHealth, the parent company of Care Improvement Plus.

"The big difference in this vs. a traditional Medicare Advantage plan is that in addition to covering hospitals, doctors, and other services, this plan is created around the chronic diseases," Leider says.

The plan's pharmacy benefit was designed around the four chronic diseases and includes a formulary specifically chosen for the diseases. For instance, members have lower copays for certain drugs used to treat the chronic diseases. The program's pharmacy benefit covers certain medications through the Medicare Part D "donut hole," the gap where most Medicare Part D benefits require beneficiaries to cover the cost of their medication.

"We want our members to continue to take their medicine and stay healthy," Leider says.

Every member in the plan is assigned to two nurses. One is a telephonic health coach who helps the members learn to manage their care and educates them about their disease.

The other is a local field nurse who works with the members face to face at Care Improvement Plus screening centers located throughout the community, or, if necessary, in the members' homes.

Care Improvement Plus started its Special Needs plan in 2006 with a smaller service area of just eight counties in Maryland. Since the plan was expanded into additional states and counties in 2007, enrollment has grown to more than 60,000 and is growing rapidly, Leider says.

Most of the members in the plan have more than one chronic condition, says Cliff Madden, RN, program manager of disease management at the Baltimore screening center.

The case managers, the disease managers, and the telephonic health coaches all work from the same computer platform and can share information on members if needed.

"We believe that the case management and disease management functions are better embedded in the community. Nurses who live in the community know the local resources and can help provide beneficiaries with the local support they need," Leider says.

The health plan leases office space in shopping centers and other locations in areas where there is a concentration of members. The screening centers are located near public transportation and on one level so the beneficiaries don't have to climb stairs when they visit.

When beneficiaries enroll in the plan, a non-clinical person in the Baltimore call center calls them and welcomes them to the program. Then they get a call from a nurse who administers a health risk assessment. The nurse gathers information using a computerized program that structures the questions according to the member's diseases and responses. She collects information about the member's hospitalizations, medications, the names of their physician, psycho-social or caregiver issues, and completes a screening for depression.

The health risk assessment stratifies the member's level of severity and determines whether he or she is appropriate for a disease management program or needs a more intensive case management program. Members receive regular coaching calls from the call center nurses at a frequency that is dictated by their risk score. The field nurses try to get all members in at least yearly for a face-to-face visit.

"Case management tends to be for the more complex patient with multiple problems. These are high-cost individuals with psycho-social issues who need a custom plan," Leider says.

For instance, if a beneficiary is a diabetic who has had a stroke, been hospitalized frequently, has family financial problems, and is being treated for depression, he or she would be placed in the case management program.

On the other hand, a member with heart failure who is taking an ACE inhibitor and a beta-blocker and is watching his diet and salt intake and weighing himself daily may be more appropriate to be monitored by a disease management nurse who works with the physician to prevent complications by following well-established evidence-based plans of care.

Members with higher risk scores receive more frequent telephone calls and are strongly encouraged to see the local field nurse for a face-to-face visit.

Those at a lower risk also get telephone calls and educational materials in the mail and are asked to come in to the screening center once a year, Madden says.

If the member lives in an area served by a screening center, the nurse transfers the member to the screening center's secretary who sets up an appointment for a face-to-face visit, Madden says.

"If they can't come in or we determine right away that they have an immediate need, like an open wound, we go out to see them in their home. We have a good compliance rate for getting members into the center," Madden says.

If the members don't have transportation to the center, the health plan offers options with a transportation benefit that provides 30 one-way trips for doctor visits or to come into the center, he adds.

Face-to-face visits are an effective way to spot problems and to improve communication with the beneficiaries, Leider points out. "It's difficult to cover health care issues on the telephone with someone with mild dementia or who has other cognitive problems or hearing loss," Leider points out.

Often the field nurses invite family members or caregivers to accompany the beneficiary to the center and collaborate on a care management plan.

The nurses at the local centers record the members' height and weight, blood pressure on both arms and ankles, and other vital signs, depending on the disease. For instance, nurses use a test to determine if diabetic members have peripheral artery disease and a vibration test to determine if there is sensation in the foot.

The sensory examination often helps diabetics who are in denial realize the serious nature of their disease, Madden says.

"First, we perform the vibration test on their hand and we can see the light go on when they don't feel it in their feet. They get a little more serious about compliance," he says.

Skin problems, wounds, or ulcers are a major complication for diabetics, Leider points out.

About 30% of patients with diabetes don't have sensation in their feet, he adds.

The nurses perform foot examinations on the diabetics and set up quarterly visits to a podiatrist who can manage any skin problems and help the member avoid hospitalization, Madden says. The plan covers six podiatry visits a year.

Members who fail either the peripheral artery disease test or the sensory test or who have ulcers or wounds are fitted with special diabetic shoes by a pedorthist whose office is next door to the Baltimore center, Madden says.

The plan provides diabetics with free glucometers, teaches them how to use them, and arranges for supplies to be delivered to the home.

The nurses encourage members with heart failure to weigh themselves daily, provide digital scales if necessary, and teach them about their disease.

Members with severe heart failure, who have been admitted to the hospital in the past year, may receive a remote monitoring device that plugs in to the telephone. The members weigh themselves on the machine and answer a series of questions that are transmitted electronically to the monitoring nurse.

If the member has problems, the nurse at the monitoring center contacts the physician directly and informs the Care Improvement Plus team as well.

"We work closely with those nurses. If a member hasn't weighed in a few days, they'll alert us and if we can't get them by telephone, we may go to the home," Madden says.

Since the program began, the nurses have discovered hypertension in a number of members. In these cases, they call the physician to make sure he or she is aware of the condition. Sometimes the physician talks directly to the members and changes medication on the spot, Madden says.

Medication reconciliation is a big part of the program. Members are asked to bring in all the medications and supplements they take.

"We want to see their medications so we can check for duplications and create a comprehensive list. When we go to their homes, we always ask if we can look in the medicine cabinet and refrigerator and see what they are taking," Madden says.

Madden encourages the members to make appointments to see their physician and follows up in a couple of weeks to make sure they have seen the doctor.

In some cases, he suggests that beneficiaries come back to the center for a follow-up visit.

"If we think they need to be seen again, we bring them back. We have tough cases that we see almost weekly. These are usually people with open wounds and we visit to follow up on the home health care treatment," Madden says.

The nurses call in social workers for assistance if the beneficiaries need community services, such as Meals on Wheels or financial assistance.

"We try very hard and do everything we can to get these patients on the right track," Madden says.

When one member kept forgetting to get his medications filled, Madden worked with the nurse practitioner at the dialysis unit who filled the medications for him every week.

The program started in January and it's too soon for Care Improvement Plus to have any outcomes information but the nurses in the field report a lot of progress, Leider says.

"We see great victories with our clients. We have gotten people set up with medications they didn't have before and we've watched them improve. We're seeing a lot of good things happening with these members," Madden says.

He attributes part of the success to seeing members face to face and taking the time to work closely with them.

The average visit lasts about 45 minutes.

"The members really appreciate the time we take with them. Their doctor visits are fairly short. We take the time to make sure they learn what they need to know about their disease," he says.