CM model follows members through continuum

CMs trained in motivational interviewing

Fallon Community Health Plan is moving toward a comprehensive case management model in which all its nurse case managers in the outpatient care services department are trained in motivational interviewing and how to determine a member's readiness to change.

Traditionally, members in different case management and disease management programs have been managed by different nurse case managers. The health plan is moving toward a model in which one case manager works with an individual member, regardless of what program he or she is in.

The new model will provide better continuity of care for members and will ensure that their care is coordinated by the same case manager if they move from program to program, such as the disease-targeted case management program or a high-risk case management program for members with three or more chronic conditions, says Paula Phillipo, RN, director of the outpatient care services department.

The health plan uses predictive modeling software to identify members for high-risk case management, based on claims data including laboratory and pharmacy data. The high-risk model is aimed at members with three or more chronic conditions.

"These members often are more acutely ill and have more comorbidities than members in our regular disease management program. They are in acute need of services and usually need interventions more frequently that members who have their chronic conditions under control," Phillipo says.

Fallon Community Health Plan began training case managers in behavioral modification techniques and motivational interviewing, based on the Prochaska Readiness to Change model in 2003. The Readiness to Change model is based on the findings of James Prochaska, PhD, professor of clinical and health psychology at the University of Rhode Island.

The first to receive training were case managers in the high-risk program. In the first year of the program following the training, an impact analysis showed that the program saved the company $10 million, Philipo says.

Case managers work with members who are at risk for hospitalization. They are identified through predictive modeling that looks at claims information and pharmacy and laboratory data and predicts which members are likely to be hospitalized within the next 12-15 months.

"The predictive modeling looks at encounter data as well as trends in omission of care. These patients may have never been in the hospital, but their data indicates that they are at risk for going into the hospital," Phillipo says. The health plan's predictive modeling software stratifies members with chronic illnesses, identifying them as low, medium, or high risk for hospitalization.

"Anyone with medium or high risk receives one-on-one contact with an RN case manager," she says. The care managers call the members and conduct a telephone assessment.

The case managers send the members educational materials and work with them on learning how to self-manage their chronic disease and avoid becoming sicker.

"They talk to the member about laboratory results, diet, exercise, and how to recognize symptoms that indicate they should call the doctor," she says.

Patients identified with one primary chronic disease, who are hospitalized for another problem, often are referred to the disease-targeted case management program by the health plan's inpatient case managers. Fallon Community Health Plan's disease target management services covers four primary chronic conditions: diabetes, heart failure, coronary artery disease, and asthma.

The disease-specific case management program also gets referrals from providers and from the members themselves. The health plan also mines its data to identify members for the program and to stratify them into low, moderate, and high risk.

The care managers stratify the high-risk members on an acuity level of 1 through 4, with members who score a 1 needing the most interventions.

Members who are at Level 4 have been in the program, absorbed the material, and are ready to graduate from high-risk case management. They could have been in the program as long as 18 months, Phillipo says.

When members are identified for case management, the care manager makes an outreach telephone call and conducts a comprehensive health screening embedded into the plan's software.

"The member may not complete the assessment during just one phone call, especially with our senior population, who don't want to be on the telephone for lengthy calls. But they start the process and, depending on how the member is responding, set up the next phone call," Phillipo says.

The health plan's software assigns the frequency of contact based on the acuity of the member and generates short-term and long-term goals and health actions.

Once the care manager identifies what stage of readiness-to-change level the member is in, the plan of care is developed, based on his or her willingness to change at that point in time.

The assessment identifies barriers to compliance. The care managers also may mail material to the members or refer them to the health plan's web site for more information.

If a member has multiple chronic conditions, the care manager works with the member to decide which is the most important one to tackle first.

For instance, a diabetic patient also may have coronary artery disease and chronic obstructive pulmonary disease. If his or her diabetes is under control and lipid levels are within a normal range but breathing is an issue, the care manager will suggest that the patient focus on breathing and energy conservation.

The frequency of contact by the nurse care specialists varies, depending on the members' needs.

"It's so individual. Some are calling the members every day or two at the beginning," she says.

As the members start to become more stable and learn self-management techniques, the frequency will fall off.

Following the success of the high-risk program, all of the health plan's case managers have undergone training on motivational interviewing techniques. All nurses in the department were previously trained on utilizing readiness to change assessment processing.

"We're also ensuring that the nurses are trained on understanding the members' benefits packages so they can ensure that necessary benefits such as home care are in place when necessary," she says.

The program has two social workers who assist members in accessing community resources that will benefit the member and/or the members' family or caregivers.

The health plan also provides complex care management services to manage members who are undergoing organ transplants and for members with complex needs, such as spinal cord injuries or traumatic brain injury.

The care starts for transplant patients when the member is evaluated for a transplant and continues for a year following the transplant, typically for a period of two to three years, depending on the type and availability of transplant.

Fallon is moving toward implementing a medication reconciliation program to make sure that members who take multiple medications are not at risk for a complication.

"If a member is seeing two or three different specialists as well as a primary care physician, they may be getting medication prescriptions from several sources, and they don't always remember to tell their doctors what they are taking," Phillipo points out.

In addition, patients may be given a name-brand drug when they are in the hospital but already are taking a generic version of the same drug.