CM guide members on end-of-life decisions

Clients are stratified to determine needs

When case managers at Highmark Blue Cross and Blue Shield talk to their members, they take steps to ensure that the members have advanced care-planning documents in place.

"We wanted to respect our members’ choices regarding advanced care planning, whether they wanted full treatment or limited treatment. We want to make sure our members know that there are options in a terminal illness. Our goal is to avoid last-minute indecisions," says Judith Black, MD, senior products medical director for the Pittsburgh-based insurer.

The health plan administration launched the advanced care planning initiative because of concerns about the high utilization of the hospital and the intensive care unit at the end of life instead of hospice and home situations. Data showed that only 15% of Highmark’s members are enrolled in hospice care at the end of their lives, and half of them died within a week. About 40% of members died in the hospital. Black used this information to demonstrate to senior management the need for improvements in end-of-life care.

"Our goal isn’t to have everyone in hospice. Our goal is to have people think about these issues so that when they are at the end of their lives, they get the kind of care they want," Black adds.

Case managers use their instincts as to which members to approach about advanced care planning.

Black encourages them to stratify the members they work with into three levels of priority:

• Those whose death within a year wouldn’t surprise the case manager.

These members get the higher priority. Case managers make sure they are involved in advanced care planning, have a health care surrogate, and have advance directives in place.

"In the case of these members, the case managers would be proactive in talking with the members about their end-of-life goals and asking the physician what kind of care might be appropriate," Black says.

Case managers talk to the surrogate if the member has a memory problem.

• Those who are older than 65 or have a chronic illness.

The case managers encourage these members to have advance directives, to designate a surrogate health care decision maker and to talk to their physicians.

• The rest of the clients who are relatively young and healthy.

Highmark’s computer software includes information that indicates whether members have advance directives. That way, case managers won’t bring up the topic over and over with members.

"The Patient Self Determination Act requires that provider talk with members about advance directives every time they go into the hospital. We didn’t want them to feel like they were getting the same questions over and over from the health plan as well," Black adds.

Here are some questions the Highmark case managers ask members:

  • Do you have someone who can make decisions for you if you are not able to make your own health care decisions?
  • Does your surrogate know their wishes?
  • Do you have a living will?
  • Would you like information on a living will?
  • Would you like to talk to a health coach about the advanced care planning process?

The health plan works with the physicians in the community so they will ask the members the same questions.