Three-pronged approach saves money, helps members avoid asthma attack
Health plan contracts with nonprofit agency for home-based services
An asthma management program that includes telephonic case management, home visits, and physician incentives has saved money and earned accolades for Priority Health, a health plan company based in Grand Rapids, MI.
In six years, participants in the HealthyEncounters asthma program reduced the number of emergency department visits for asthma by 26% and increased the use of proper medication from 69% to 98%, according to Mary Cooley, RN, BSN, MS, CCM, senior manager of case and disease management at Priority Health. During the same time, hospital admissions for asthma dropped dramatically for both the health plan's commercially insured and Medicaid members.
In 2005, the health plan saved an estimated $1.5 million when actual costs were compared with expected costs, Cooley says.
The health plan's model received the National Leadership Award from the U.S. Environmental Protection Agency (EPA) as well as the Region 5 National Exemplary EPA award and the Michigan Association of Health Plans' Pinnacle Award for chronic illness.
About 8,000 people insured by Priority Health have persistent asthma. The health plan's goal is to help them understand their disease and learn to manage it by using medication properly and avoiding situations that can trigger an asthma attack, Cooley says.
"Asthma is quite misunderstood. Persistent asthma is a chronic disease but many people treat it acutely. They go to the emergency department and receive nebulizer treatment, which makes them feel better so they don't follow up. They don't understand that they need to take daily controller medication," she says.
The program takes a three-pronged approach to asthma management combining case management and disease management, community partnerships, and provider initiatives.
Case managers and disease managers work telephonically with members who are at risk for an exacerbation and refer those who are at highest risk for face-to-face case management provided by the Asthma Network of West Michigan, a grassroots, nonprofit agency.
Priority Health was the first health plan in the country to provide reimbursement for home-based services to members with asthma, Cooley points out.
"This partnership underscores Priority Health's commitment to its members as well as to the community," Cooley says.
The Asthma Network sends certified asthma educators, who are nurses or respiratory therapists and act as case managers, into homes to assess the home for environmental issues that could trigger an asthma attack, provide education and support, says Karen Meyerson, MSN, RN, FNP-C, AE-C, manager of the organization.
After the referral, the Asthma Network case managers take over care coordination for Priority Health members who agree to participate in the voluntary program.
"We contact them if necessary and provide a discharge summary when the member completes the process. It's a seamless process," Meyerson says.
The community case managers work with the members' physicians to create an asthma action plan, visit schools and daycare centers that members attend and provide asthma education to the staff, and work with the members to ensure that they are following their treatment plan.
'Eyes and ears in the home'
"We realized that our case management program is excellent but we did not have the ability to assess the members' environment. We needed eyes and ears in the home," Cooley says.
The health plan pays for up to 18 home visits a year for members with high-risk or difficult-to-control asthma, Myerson says. "Some members don't require 18 visits to learn how to manage their asthma. Others need long-term support," she adds.
Initially, the asthma educators visit the families every two weeks for three months, presenting a series of six asthma education sessions. After that, they visit the family once a month if they feel the family needs more support, or more often if appropriate.
"We follow the members for a year and help them learn how to manage their disease through the seasonal changes and to deal with environmental and psycho-social concerns," Myerson says.
They educate the members about their disease; make sure they are using the right tools, such as peak flow meters and inhalers, and teach them to use them correctly; work with the family on trigger management; and help them understand what factors in their home could be contributing to asthma exacerbations.
"The most important part of the visit is to assess the home environment for triggers. The personal assessment helps them identify problems that we may not find out about over the phone. If we ask a member if anyone in the family smokes, they may or may not say yes but the case manager visiting the home can smell it if someone is smoking," Cooley says.
The on-site case managers look for pets or evidence of cockroaches, dust mold, and water stains on the ceiling that indicate proliferating mold. They zero in on the bedroom and may recommend removing the carpeting or encasing pillows and mattresses in a plastic cover.
Making home modifications
The organization has a social worker who can help the family get assistance for home modification issues, such as removing carpeting or getting an exterminator to deal with a cockroach problem.
The case managers who visit the homes can also identify physical and psycho-social problems the members may be facing and call in a social worker for assistance, Myerson says.
"Many of the families we visit are living from crisis to crisis. Life gets in the way of complying with their asthma treatment plan. They're worried about not having enough food or being evicted and have to deal with whatever bubbles to the top of their list. They have so many issues, that a chronic disease is at the bottom of the list until they have an attack," Myerson says.
The social worker can help the family find assistance with issues such as housing and transportation so the asthma case managers can help patients learn to treat the disease as a chronic condition, rather than wait until they have an asthma attack.
Having someone go into the home and assess a member's living condition and home life helps the health plan's case managers understand the obstacles to following their treatment plan that the member may be facing, Cooley says.
"We know that we need to deal with the psycho-social issues that people confront in their everyday lives before we can tackle the asthma issue. Our community-based model helps us see what the barriers are and help the members overcome them," Cooley says.
Once the Asthma Network case managers have completed their work, the Priority Health case managers pick up the cases.
"We pick up the case to make sure they understand their asthma action plan and that they comply with their treatment plan so that the outcomes are sustainable over time," Cooley says.
Priority Health began its asthma disease management initiative in 1995 with a population-based health management initiative. The health plan created an asthma registry that contained the names of all members with asthma, stratified by risk level.
The members in the HealthyEncounters program receive targeted interventions based on their risk level.
High-risk members include those who have been hospitalized for asthma, who have multiple emergency department visits for asthma, and those who are overusing their rescue medicine or under-using their control medication.
"Our case managers reach out to every member who is at high risk. One of our current innovations is to move upstream and touch members with moderate risk as well. We always have taken a reactive approach and worked with the members who are having difficulties but we also want to take a proactive approach and target people upstream who haven't yet had a crisis. We want to keep them from reaching that point," she says.
Referring members in real-time
As part of its vision to provide assistance to people "just in time" the health plan has implemented an on-line stratification tool that refers members who are newly categorized as moderate or high risk to the case management department on an ongoing basis.
"My nurses are apprised of new cases on a weekly or bi-weekly basis," Cooley says.
In addition, the case managers receive e-mail alerts as soon as a member they are managing hits a risk factor, such as refilling his or her rescue medication too frequently or having an emergency department visit for asthma.
"Our interactive tools not only notify the case managers when new members are at risk but it gives them real-time information that helps them manage the care of their patients," she says.
The health plan is in the process of implementing between 15 to 20 different alerts into its software system to automatically notify case managers when members are newly diagnosed or hit certain thresholds.
"Our case managers will be able to click onto a dashboard when they receive an alert that a member has hit a risk level. Then they can pick up the phone and call the member to find out how they are doing. This gives the case manager an opportunity to help the member avert a potential crisis and avoid an emergency room visit or a hospitalization," she says.
The health plan offers provider tools that include a patient profile that identifies all patients with asthma who are covered by Priority Health. The physicians can use the tool to identify patients who are not refilling controller medication or refilling rescue medication too frequently.
In addition, physicians who meet quality benchmarks for asthma care receive additional reimbursement from the health plan.
"We give the physicians the tools to make them successful in treating their patients with asthma and we incentivize them to meet quality benchmarks," she says.