Plan complements disease management program

Targets ill at risk for health care expenditures

Members with chronic conditions that put them at risk for high health care costs but don't fall into traditional disease management programs are learning how to manage their conditions through the ComplexCare program from Health Management Corp.

"We've recognized for a long time that dealing with the core disease management conditions can have a positive outcome for people who are at risk, but there also are people with multiple chronic conditions who do not fall into traditional disease management categories but who account for a lot of expense and poor outcomes," says Sam Cramer, MD, chief medical officer for Health Management Corp.

Health Management Corp., a wholly owned subsidiary of WellPoint, with headquarters in Richmond, VA, supplies disease management and case management for WellPoint and other clients.

ComplexCare helps members avoid preventable episodes of care by seeing a physician regularly and following their care plan, complying with their medication regimen, setting lifestyle goals, and following healthful practices, such as dieting and exercising.

The program provides outreach to at-risk members who may have conditions such as cancer, multiple sclerosis, muscular skeleton problems such as fibromyalgia and behavioral health conditions such as schizophrenia and bi-polar disorder. Members with the core disease management conditions — asthma, diabetes, chronic obstructive pulmonary disease, heart failure, and coronary artery disease — are referred to the health plan's traditional disease management program.

Predictive model used to identify members

The health plan identifies members through a predictive model that is based on utilization and laboratory claims and targets those who appear to be at risk for future utilization. For example, the model identifies members who regularly see three or more doctors, have three or more emergency room visits within six months, or have more than two hospital admissions in a three-month period. Additional members who might benefit from the program come from the results of a health risk assessment, referrals from physicians, and the health plan's utilization management department.

When members are identified, a health outreach specialist calls them on the telephone, explains the program to them, and enrolls them if they are willing to participate. The outreach specialists collect initial demographic information, and then transfer members to an RN care manager. The care manager verifies the member's medical history and diagnosis, then conducts an assessment of the member's functional status, social and economic status, support system, and any needs they may have beyond their medical condition.

"So many things besides a patient's medical condition have an effect on their health. We do a very complete assessment in terms of medication, transportation issues, the type of support they have at home and use the information to develop a care plan that looks at all of their needs and what we can do to help," Cramer says.

The care managers provide information that helps the enrollees understand their conditions and their medication instructions. They work with the members to develop a care plan that includes lifestyle goals and health-related priorities.

"The goals are based on the most important steps that the member should take to stay healthy, and at the same time, the care manager takes into account what goals the individual is most ready or most willing to work on. They have to balance the two," Cramer says.

For instance, if the member needs to stop smoking or lose weight but isn't ready to address that issue, the care manager and member may decide to start to work on medication compliance and tackle smoking or weight loss later.

"It's not just the nurse and clinicians who drive the care plan. We want the individuals to buy into it," Cramer says.

The care manager may contact the member's primary treating physician to determine or clarify a plan of care for the member. The care manager notifies the physician that the member has enrolled in the program, and shares the member's care plan and the goals, and provides status updates. The care managers work with the members to help them follow their physicians' plans of care.

"One of the roles of the nurse care manager is to make sure the members have providers and see them on a regular basis. Some have lost contact or don't have a primary care provider. The care managers facilitate getting the members in to see their physician," Cramer says.

The plan has medical director oversight at every call center who reviews the new enrollees and is available for consultation if the care manager needs information or if the treating physicians have a question.

Members are stratified by acuity level, which drives the frequency of the telephone calls from the care managers. The nurse care managers call participants at least once every six weeks. Members also can contact the nurses with any health-related questions using a toll-free number.

The program is designed to provide support for six months to a year to help members meet their health care goals. If a member is still not meeting his or her goals after a year, the nurse care manager consults the medical director to determine if the member is still appropriate for the ComplexCare program or if he or she might benefit more from a different type of program.

The care managers help members obtain referrals for specialty care, home health services, durable medical equipment, and other needs. They also work with members to help them obtain community services such as free transportation for health care visits, Meals on Wheels, or other services.

"We are not CPAs or lawyers, but our members may need these services. Beyond dealing with the clinical issues, we help the members find the resources they need to solve their problems," Cramer says.

Care managers located at call centers around the country coordinate the care of members nationwide. The care managers have resource guides for individual areas and rely on other colleagues at other locations for help in identifying the community organizations that can help the members.

"The nurse care manager is the expert in terms of resources. They don't know every resource in every location but they know how to find them," Cramer adds.

The care managers also conduct assessment screenings to identify members who might benefit from a mental health program. "People with chronic conditions frequently become depressed and depression can have an impact on their medical condition. They may not be as compliant as they should be because of mental health issues," he says.

If the care manager identifies that the member has severe behavioral health or mental health issues, she connects him or her with a mental health program and follows up to make sure that the member has kept his or her appointments.

The care managers assigned to the member work with the pharmacy staff on medication compliance. They can consult with exercise physiologists, dieticians, and other ancillary providers if needed.