Fibromyalgia program helps members avoid ED

Members encouraged to take active role in care

In the first two years of Blue Cross and Blue Shield of North Carolina's fibromyalgia management program, the inpatient admission rate among members enrolled in the program decreased by 23.3%, emergency department visits dropped by 23.1%, and physician visits went down 16.6%.

Before the program began in 2003, members who enrolled had visited an average of three different medical practices over a six-month period. A year after the program started, the number of different medical practices members visited had dropped to two.

Members replying to surveys from the health plan indicated an increase in awareness of the causes and triggers of their fibromyalgia symptoms, knowledge of how to manage their condition, and knowledge of treatment options.

The fibromyalgia program grew out of a disease management program that targeted members who made frequent visits to the emergency department, says Brian Ellison, MPH, director of health care evaluation for the Chapel Hill, NC, health plan.

"Over time, we saw that there were a significant number of people with fibromyalgia who were coming to the emergency room for treatment. We saw an opportunity for Blue Cross and Blue Shield of North Carolina to be a leader in helping members who suffer from this condition," he adds.

Fibromyalgia is a set of symptoms that includes debilitating fatigue, pain in the muscle and soft tissues, and sleep disturbances. Many of the members with fibromyalgia had been told over and over by their doctors that the symptoms they were experiencing were in their head.

Many people with fibromyalgia miss work frequently or don't work at all, Ellison says.

"People with fibromyalgia often wake up in the morning and feel like they've been run over by a truck. There is a really high percentage of people with the condition who are disabled," he adds.

The program provides 24-hour access to a health coach nurse who specializes in fibromyalgia and helps members learn to recognize what causes their symptoms and supports them in lifestyle changes that may give them relief. The company sends the members educational materials on the condition, a personal health organizer where members can maintain their medical records, tips for talking with their doctor about the condition, and a free book on fibromyalgia.

"The most important thing the program does may be to let the member know that someone understands that he or she is in pain and offers to help them. That sympathetic ear is really important to people with fibromyalgia because it validates that their condition is real," says Susan Pfannenschmidt, MS, program evaluation consultant.

Two nurse case managers at the health plan support the members during business hours. Blue Cross and Blue Shield of North Carolina contracts with a call center to handle calls after hours.

"People with fibromyalgia often have sleep disorders. We give them an opportunity to speak with someone at 3 a.m. when they can't get back to sleep," she says.

Members are identified from claims and may self-refer by calling the health plan or enrolling on the Internet. New program participants are asked to fill out a health assessment survey and return it.

The health plan created a television commercial with details on the program and immediately saw a spike in members who wanted information on the condition.

The health plans sends out an invitation package describing the program, asking the member to fill out a short health survey and listing the resources they'll have if they enroll in the program.

"We have found that many people don't respond right away. We follow up, either by additional mailings or by telephone calls," Ellison says.

When a member indicates a willingness to participate in the program, one of the in-house nurses calls and goes over the member's responses to the survey, adding a personal history, and trying to determine their readiness to change.

"We have learned to be careful not to try to get a full history the first time we talk to them. Most people with fibromyalgia have gone through that exercise six or seven times and we don't want to make them repeat it," Ellison says.

The in-house nurses have been trained on how to help fibromyalgia patients manage their condition and have an extensive knowledge of the resources available, Ellison says.

The nurses talk to the members about fibromyalgia and some of the things they can do that will make them feel better.

For instance, clinical data show that the more sedentary people with fibromyalgia are, the worse the condition gets. The nurses encourage member to participate in some kind of physical activity, Ellison says.

"We try to determine the member's readiness to change and what we can do to get them to the next level. We start with simple things to get them started changing their lifestyle. If someone is sedentary, we might suggest that they start exercising by walking around the block," he says.

The nurses offer suggestions on how to improve sleep patterns and urge the member to keep a sleep diary, with details about diet and medications that may be interfering with sleep.

"It can be a vicious cycle. If sleep patterns are interrupted, it can increase the symptoms of fibromyalgia," Pfannenschmidt says.

The nurses follow up with the members in the program at least once a month to make sure they are sticking to their regime.

Members who take a more active role in their care are more satisfied with medical treatment over time and more satisfied with the program, Pfannenschmidt adds.

They coach the patients to work closely with their physician and to take an active part in their health care plan. Before each visit, they prompt them with questions to ask the physician, then follow up to find out if the treatment plan has changed and to reinforce what the patient heard from the physician.

"We don't want to become a replacement for the doctor. We're a resource that supplements the doctor's care and supports the members in making lifestyle changes that will help them better manage their condition," Ellison says.