DM, CM, concurrent review work together
Great-West Healthcare’s disease management approach won the Denver-based company the award of best disease management program in a national PPO for 2002-2003 from the Disease Management Association of America (DMAA).
"The DMAA award represents our commitment to working with providers and members to manage chronic diseases. We were unique among programs that received awards. While others were cited for managing specific diseases, we got an award for our entire program," says Terry Fouts, MD, chief medical officer.
Since beginning the programs three years ago, Great-West Healthcare has experienced a reduction in bed days, an increase in physician visits, and pharmacy compliance among members in the disease management program.
The company’s integrated Medical Outreachsm program, which includes disease management, complex case management, and concurrent review, has garnered a 7% net savings and a 2:1 return on investment.
Great-West Healthcare’s disease management program covers a number of conditions and diseases. The company offers chronic condition management for members with asthma, diabetes, and cardiac conditions. Neonatal care management and oncology management also are offered. More programs will be added in 2004, Fouts says.
The health plan focuses its chronic condition management on the three diagnoses that drive nearly 80% of its costs, according to Fouts.
"The second reason we picked them is that we realize this is an area where we can support members and physicians in health care delivery transactions. These are chronic diseases that require a lot of patient self-management and a lot of education. There is a lot that goes on between appointments," he says.
The company has outsourced the acute care portion of its neonatal care management to Paradigm Health Services and has partnered with Quality Oncology for its oncology management services while the member is in active treatment.
Paradigm case managers go on-site to manage Great-West Healthcare members in the neonatal intensive care units and feed information to the company’s case managers on a daily basis. When the infants are released from the hospital, the neonatal case managers in each region take over the care.
Quality Oncology handles the members’ care between diagnosis and recovery. Once the patient’s acute treatment is completed, the Great-West Healthcare case managers take over managing the care.
Primary nurse model
Great-West Healthcare uses a primary nurse model, which means that in most cases the member deals with a single nurse case manager. The nurses are generalists who undergo special training in managing the care of people with chronic diseases.
"When members are in any of our case management or disease management programs, they deal with an individual nurse whenever they are available. If the member interacts with the same person, it makes a better program," he says.
In addition to educating the members about their conditions, the Great-West Healthcare disease management initiatives make sure the patients are engaged with their physicians and that they are compliant with their medication.
"As a physician, I realize that I can’t be with a patient every minute of every day. Great-West Healthcare is trying to be a supportive resource for members and for physicians," he adds.
Many people with chronic diseases tend to put off seeing the physician even though indicators, such as an increase in blood sugar level for diabetics or weight gains for those with congestive heart failure, show that they should seek medical attention, Fouts says.
"We try to get them to re-engage with their physician when these indicators occur, even though they may not have an appointment for a month or two," he adds.
Other members have prescriptions that they don’t fill or don’t refill.
Members are identified for the program through clinical and pharmaceutical claims.
Some are referred from physicians. Others come through internal referrals.
"At Great-West Healthcare, we integrate health care delivery the old fashioned way — we sit next to each other. In each of the regions, the case managers, disease managers, and concurrent review nurses sit together," Fouts adds.
For instance, if a case manager is coordinating the care for a member in the hospital who has been newly diagnosed with diabetes, she will refer the member to the disease management staff. "Because we approach our clients a little differently, I am often in front of our clients. We have a good relationship with the human resource directors and we also get referrals from them," he says.
Members who are identified for the program are asked to complete a health risk appraisal questionnaire on-line, over the telephone, or with the help of a nurse. The health risk assessment takes about 20-30 minutes.
"We can look at the claims to stratify the members, but no computer tells you whether or not somebody understands their disease. That kind of information comes out in the discussion with the nurse," Fouts says.
Those who are stratified in the mid-to-high levels receive a call from a nurse who goes over their condition with them and discusses what they need to do to keep the disease under control.
"The stratification predominately focuses on how well they understand their illness. They could be newly diagnosed with diabetes and not understand the condition. They would need more intensive care immediately and then they could be reclassified," Fouts says.
Those who need only occasional interventions receive information through the mail, educating them about their disease and giving them a number to call for more information.
Members in the middle level need some person-to-person attention and get a telephone call from a disease management nurse.
High-level members with intense needs receive more frequent interventions and may receive equipment such as a scale or a glucometer if they need it.
The member and the nurse case manager agree on a plan, which the nurse takes to the physician for his or her approval.
"It’s a three-way relationship — the member, the doctor, and the health plan," Fouts says.
The disease management nurses call the members at regular intervals, depending on the care plan and the member’s needs. For instance, if a member says he or she is going to quit smoking, the nurse calls in a few weeks to see how it’s going.
"The frequency of telephone calls they receive varies, depending on the member. A diabetic who is not obese and not a smoker wouldn’t be called as frequently as someone with a lot of comorbidities," he says.
"Generally nobody has just one thing to manage. Diabetics often have high blood pressure, obesity, and maybe depression," Fouts says.
The nurses make notes of their conversation during each call and follow up on those notes when they call again. For instance, if a member needs to lose weight, the nurse will ask if the information on grocery shopping helped. The member may say that his family isn’t cooperating. The nurse will bring the subject up during the next conversation.
"Every disease management program is based on the Prochaska readiness to change model. [James Prochaska, PhD, a professor of clinical and health psychology at the University of Rhode Island, has written extensively about readiness to change and has developed a model for it.] Members are ready to change at different rates so the nurses work around that as well. We know that just making contact doesn’t necessarily mean the patient is going to do everything he or she needs to do," Fouts adds.
The program currently is an opt-in program in which patients have to agree to join. Great-West Healthcare plans to change to an opt-out program over the next year.
"One reason we’re moving to opt out is to get a higher participation level. I’ve seen statistics that show that in an opt-in model, 35% is a good participation rate; but if the member has to choose to opt out of the program, you get a 92% enrollment because you have a hook on them," Fouts says.
One challenge in recent years has been to steer members who are researching their conditions toward valid medical advice on the Internet.
"There are about 35,000 web sites that address health topics. Some are at best borderline and at worst misleading. We want our members to have access to information that has been reviewed at an academic center instead of going to the Internet and just picking any answer," Fouts adds.
The program attempts to steer members toward medical web sites that have clinically valid information about their conditions through links on the Great-West Healthcare web site and written materials sent to members.