Disease managers visit asthma patients in the ICU

Members are more agreeable when in crisis

When members of Passport Health Plan are hospitalized in the intensive care unit for asthma, the plan's asthma disease managers visit them on-site and work with the hospital's asthma educator to help them learn to manage their disease.

"In the beginning, we attempted to reach the high-risk members telephonically, but the high volume of members was difficult to manage on a one-on-one basis. We decided to concentrate on members who are in the intensive care unit because they are at most risk and tend to be more willing to allow the disease manager to work with them when they receive a personal visit while they are still in the crisis mode," says Amy Vissing, RN, BSN AE-C, asthma disease manager for the Louisville, KY-based HMO.

Last quarter, the disease managers provided one-on-one care management to 88 members in the intensive care unit. The majority of members who receive individual disease management visits in the hospital are children.

"We have a large population of children with pure persistent asthma. The adult population tends to have emphysema or chronic obstructive pulmonary disease as well, says Terry Watson, manager of Passport's health management department.

The disease managers have worked with the hospital's case managers, utilization review nurses, and asthma educators, asking to be notified when a member is hospitalized in the intensive care unit with asthma.

"When we find out about a member who is in the hospital, we attempt to make a visit to the hospital and talk with the parent or guardian and the patient about the asthma. If they are in agreement, we follow them one-on-one and may accompany them on their first follow-up visit to their physician and get them connected to a specialist, when needed," Vissing says.

At one time, the disease managers provided individual care management following reports culled from the claims data.

"That data was old, since it was based on claims. It had been two to six months since the member was in the intensive care unit. By then, their acute episode was over and we had trouble getting them to agree to continue our interventions," Vissing says.

Many of the health plan's members are transient and often are difficult to locate.

"When we meet them in the hospital, often they will give us their new phone number or their new address. That's been one of the biggest pluses for the one-on-one piece," Vissing says.

The disease managers follow the patients for as long as they need interventions, sometimes for a year or more.

"Some of the children are very severe and require a lot of interventions," Vissing says.

Passport Health established its asthma disease management program in 2000 with a goal of improving the quality of life for members with asthma and reducing unnecessary asthma-related hospitalization and emergency department use.

HEDIS data from the National Committee for Quality Insurance rank Passport Health Plan in the top 10% of plans nationally for use of appropriate medications by people with asthma.

Using claims data, the health plan divides members with asthma into five groups, based on the severity of illness and the services they have used.

All members with asthma receive a welcome package, a peak flow meter, and monthly educational mailings.

The health plan sends members with asthma periodic educational materials, such as an asthma pocket guide that explains what patients should do every day and what steps they should take in case of an emergency.

"What members don't recognize are the persistent symptoms of asthma. They can be very inconspicuous, such as frequent nighttime coughs," Vissing says.

High-risk members are those who have been hospitalized with asthma, who have utilized the emergency department, or have been admitted to the intensive care unit.

Quarterly, out of about 6,000 members with persistent asthma, about 200 are considered high risk.

Passport Health mails extra information to high-risk members, urging them to talk with their physicians about controller medications. Additionally, Passport sends letters to providers, alerting them that members have been designated at high risk, based on their utilization of services for asthma.

"We attempt to make telephone contact with adult high-risk members and tell them about the program. We have access to information about their medication. If we can't talk with them, we send them a letter saying we noticed they have not refilled their controller medication and ask them to contact the pharmacy for a refill as soon as possible," Vissing says.

The plan pays for an environmental assessment and a follow-up visit by a home health agency.

The health plan mails asthma assessments to newly identified members with persistent asthma. Last month, the health plan received 354 completed assessments.

"We're filtering through the assessment and contacting members who need more interventions," Watson says.

The asthma disease managers work closely with providers who see a high volume of members, visiting them in person, providing them with educational materials, and encouraging them to follow guidelines from the National Institute of Health's Heart, Blood and Lung Institute.

"When we go into the physician offices, we teach the staff providing asthma education to our members how to use the various types of inhalers. There are a lot of different types of devices, and the amount of medication that patient receives is directly related to how well they are able to use the device," Vissing says.