Nurses in integrated program follow clients through continuum

The same person handles case management, disease management

When First Health Group Corp. began looking at disease management programs in the mid-1990s, the preferred provider organization (PPO) decided to develop a fully integrated system, rather than setting up disease management programs for each diagnosis.

As a result, one nurse case manager follows a patient throughout the continuum and manages his or her disease or diseases.

For instance, if a patient has congestive heart failure and diabetes, then is hospitalized for cancer surgery, the same nurse case manager follows the patient throughout the continuum.

"We call it a fully integrated program. We feel that you need to look at it from a member’s perspective. When patients are handed off back and forth among programs, information can be lost," says Scott P. Smith, MD, MPH, national medical director for First Health, the nation’s largest directly contracted PPO organization, based in Downers Grove, IL.

At First Health, the nurse case managers follow patients throughout the continuum, regardless of what happens.

For instance if a diabetes patient is diagnosed with cancer and needs individual case management for that disease, the nurse assigned to manage the patient’s diabetes follows him or her all the way through hospitalization and treatment.

"We didn’t want to carve out the management of these patients. We thought it would be counterproductive to have three different nurses work with a single patient on three different diseases," Smith says.

The Care Support Program is overseen by 25 medical directors and supported by 21 case managers and coordinators who manage members with 10 chronic conditions — diabetes, congestive heart failure, asthma, depression, atrial fibrillation, heart attack, hepatitis C, organ transplant, high-risk maternity, and HIV.

About 40% of the members are in more than one program.

First Health rolled out its Care Support Program in January 2000 after a team of in-house physicians designed the program and created the protocols for handling patients referred to case management.

The physician team took externally developed guidelines for management of the diseases and processed them into clinical tools for the nurse case managers. Each protocol has a set of interventions and outcomes measures.

"The disease management concept rang a bell for us. In this organization, we’ve always believe that the most fruitful ground for quality and cost management is with chronic diseases," Smith says.

The program works well because there is physician support that the nurse case managers can call on for assistance, he says.

"If you have a totally nurse-driven system, there may be value in hiring an outside vendor or an expert. The nurses have physician backup, and this works out better for the member and for us, too," Smith says.

When a patient is assigned to a case manager, she reviews the information and contacts the member. In the case of members who are already in the system but have a new condition to be managed, the nurse re-contacts them.

The program is voluntary, but the case managers assume that the patient wants to be involved unless the patient tells them otherwise, Smith says.

Patients are divided into four categories: High risk, high need; high risk, low need; low risk, low need; and low risk, high need.

Those with low risk and low need receive educational materials and a telephone call every six months unless they have an incident that triggers a higher level of care. Those with high risk and high need may need to be monitored every week.

The information the nurse enters into the computer program during the initial assessment triggers the next step the nurse takes. For instance, if the patient has congestive heart failure and is not on ACE inhibitors, the nurse may notify the medical director to call the physician about the issue.

"We don’t put the patient in the middle by suggesting that the doctor isn’t doing the right things. We know that doctors tend not to respond well to nurses who question their care. When we have an intervention that requires direct contact with the physician, unless it’s just to give them information, we involve our medical staff, who call the physician to discuss it," he adds.

Generally, one nurse is assigned to a population of about 9,000 members. These all may be employees of one client, or one nurse may be assigned to cover members from several small employers.

"A nurse may be following 50-100 cases but only a few patients who need really intensive care. We don’t have set numbers or productivity requirements," Smith says.

The nurses may have several cases that need full case management and a number of disease management clients who need only occasional care.

The case management services are handled out of company call centers in Downers Grove, IL, and Scottsdale, AZ. The call centers are staffed 24 hours a day so the case managers can reach members who travel or work odd hours.

"Staffing the call centers is everybody’s responsibility. We let it be known up front that case managers may be working nights and weekends," Smith reports.

The program has received rave reviews from the members.

"Our members have told us in satisfaction surveys that having one nurse to call on is the best part of the program. The health care system is so complicated that they welcome having one person to help them with it," Smith says.

Financial outcomes show an increase in pharmacy costs and decrease in medical costs for patients in the disease management programs.

Patients are reporting less time off work and increased use of beta-blockers, inhalers, and other medications and procedures connected with chronic disease management.

"The key to our ability to do this is that we have the physician backup. The nurses are not out there on their own. If they’ve got an unusual situation, they can consult with the physician," Smith says.