Demonstration project improves outcomes for ill

CMs work with patients by telephone and face to face

A Medicare demonstration project in Florida that includes both telephonic case management and face-to-face interventions has improved clinical outcomes for beneficiaries who are eligible for both Medicare and Medicaid and have congestive heart failure or any combination of comorbidities that include congestive heart failure, diabetes, and coronary artery disease.

The program, which started in 2005, has been so successful that the Centers for Medicare & Medicaid Services (CMS) has extended its contract with LifeMasters Supported SelfCare, an Irvine, CA-based provider of health improvement services.

"The program has demonstrated cost-effectiveness to Medicare, and our preliminary analysis indicated that we have improved the clinical outcomes for a very difficult-to-manage population," says Christobel Selecky, CEO of LifeMasters.

The goal of the program is to reduce preventable utilization with a combination of health coaching and lifestyle changes, Selecky says.

CMS is measuring the outcomes for the group that LifeMasters is managing against a control group.

There are about 28,000 participants in the program.

"We are showing good results in our population compared to the control group and are slightly above break-even for the new cohorts in the program. People who have been in the program since it began in 2005 are getting older and sicker and experience higher health care costs than the new participants," Selecky says.

Participants in the disease management program are followed by nurses in a call center called clinical nurse consultants (CNCs) and/or community-based case managers called community service RNs (CSRNs) who work with the beneficiaries in their homes.

"The team in the field and the team at the call center are extremely tightly integrated and refer back and forth to each other," Selecky says.

Referrals for the program come into the call center where specialists complete an evaluation and determine if the person's care could be coordinated over the telephone or if they need face-to-face care, says Vicki Manning, RN, community services RN team manager.

"It's a seamless system. If the clinical nurse consultants at the call center has concerns about one of the participants, they send a referral to the community service RN or social worker to evaluate the participant in their home," she says.

"LifeMasters' goal is to manage as many people as possible by telephone, because successful programs need to be scalable. However, to ensure that all participants are getting the help they need, different options must be provided," Selecky points out.

About 30% of the participants have had a face-to-face visit with a LifeMasters nurse at least once, but only about 94% of them are followed regularly by the clinical nurse consultants in the call center.

"People tend to have the preconceived notion that a telephonic program won't work with older or underserved participants, but it does work if there is an outlet for other interventions when required," Selecky says.

When CMS sends LifeMasters the names of individuals eligible for the program, LifeMasters contacts the beneficiaries and invites them to participate in the program, then sends a letter to their primary care physicians explaining the program. The participants are assigned a nurse who calls them on a regularly scheduled basis.

"The frequency of contact depends on the severity of the individual's conditions. Many of the participants are not accustomed to focusing on their health, and the nurses may gradually ease them into managing their condition," she says.

Selecky attributes part of the success of the program to a unique method of stratifying participants, a combination of traditional stratification based on utilization and cost of care with the Patient Activation Measure, a tool that assesses an individual's likelihood to engage in making health care changes.

"In the past, disease management programs have stratified people primarily based on their utilization and the cost of their care. We are being held accountable for reducing health care costs, and we need to give priority to the most severe. However, over the past year, we have implemented a new way of further stratifying participants based on their activation level," she says.

The Patient Activation Measure assesses a person's knowledge, skills, and confidence in playing a role in their own health care and ranks them in one of four activation levels according to their engagement in health care.

"We have researched this method and found that if the nurse tailors the conversation according to what level of activation the person is at, we can make a dramatically different impact," she says.

The nurses use the results of the Patient Activation Measure and the participant's level of severity to gear their encounters, using motivational interviewing techniques.

For instance, patients on Level 1 of the activation scale feel they can make no impact on their own health. Therefore, trying to persuade them to get a lab test may be a waste of time. Instead, the nurses help them understand how they can have an impact on their own health and move them toward the next level of activation.

"Research shows a correlation between the level of activation and actual self-care. If we focus on moving them out of the activation level, they start to show behavior that drives improved outcomes," she says.

"The combination of motivational interviewing and patient activation has resulted in much better retention in the program because the participants aren't frustrated by being asked to do things they aren't ready to do," she says.

Because understanding a participant's current clinical status is important to avoid costly but preventable exacerbations, LifeMasters provides the tools that the participants need to use to take and report their vital signs and symptoms on a daily basis. The congestive heart failure patients receive a scale and a blood pressure cuff, and the clinical nurse consultants teach them to enter data on weight, blood pressure, and other vital signs through the Internet or through a touch-tone phone.

"The information they input goes into our system, where it is measured against national guidelines. If the system flags someone with signs that could signal a clinical exacerbation, the nurses call them and find out what's going on," she says.

In about half the cases, the nurse identifies a behavioral reason for the out-of-bounds event and uses the call as a teaching moment. For instance, a patient might be having symptoms of an exacerbation because of non-adherence to the drug regimen. If the nurse can't determine a behavioral reason for the problem, the system creates an alert that is faxed to the physician for follow up.

LifeMasters has tested combinations of approaches with participants to see which method works best in getting people to participate at the appropriate level.

"We know from our own research that if you compare people who have a regular relationship with a nurse to people who get just a newsletter and periodic follow-up, there is an improvement of several hundred dollars per member per month in cost savings. Obviously, it is worth it for us to deploy a lot of resources to find ways to engage patients," she says.

Different approaches include sending an introductory piece to a family member or physician instead of the participant and whether to have a nurse or a non-nurse make the first call.

"We have good enrollment and good engagement in the program. Research has led us to expect that about 20% of participants in our standard populations would be highly engaged and willing to monitor their vital signs and interact with the nurse on a regularly scheduled basis. In this group, about 35% are highly engaged, a substantial percentage for this population," she says.