Motivate challenging patients to take control of their own health

CM's one-on-one skills are the answer

Soaring health care costs and an increase in the number of patients with multiple comorbidities or other barriers to compliance represent an opportunity for case managers who have the skills to work one-on-one with individuals to empower them to take charge of their own health care, says Connie Commander, RN, BS, CCM, ABDA, CPUR, national president-elect of the Case Management Society of America (CMSA) and owner and president of Commander's Premier Consulting Corp.

This challenging group of patients needs more than just generic population-based information about their disease, she points out.

"If you really want to motivate the individual, you have to talk to them on a one-to-one basis. Chronically ill people are not going to be motivated to adhere to their treatment plan without having regular one-on-one contact with a case manager," Commander adds.

Health plans across the nation have adapted numerous strategies to increase adherence among the 20% of their member population who consume 80% of the health care expenditures.

"The challenge is getting to them, educating, empowering, and motivating them to adhere to the suggested treatment and care guidelines. This means educating case managers to the skill level they need to be able to listen and communicate effectively and motivate patients to adhere to the plan of care," Commander explains.

In the 1990s, with the advent of disease management, insurers started targeting populations with chronic diseases and developing standards of care such as regular foot and eye exams for diabetic patients, she says.

"We expected that if we educated people about their disease and sent them reminders about the tests and procedures they needed, that they would be compliant. But somebody needs to follow up, and that's where the individual case manager comes in," Commander says.

For instance, Fallon Community Health Plan is educating all of its case managers on the Prochaska "Readiness to Change" model and on how to conduct motivational interviewing, says Paula Phillipo, MD, medical director, disease care services.

Using the skills they developed during training, the case managers can adapt their approaches to the members based on what stage of readiness to change the members are in.

The Case Management Society of America has developed Case Management Adherence guidelines designed to guide case managers in helping their clients stick to their prescribed medication regimen, Commander says.

"The guidelines assess an individual's understanding of his disease and how willing they are to take the steps necessary to stay well. Using the Case Management Adherence Guidelines, the case manager initiates back-and-forth communication, trying to motivate the individual member on their level of readiness and to empower them to take on their own health maintenance," she says.

No matter what program a case manager is working in, it takes a personal touch and one-on-one contact to get patients with chronic illnesses to make the kind of changes in their lives that are necessary to prevent major exacerbations of their disease, Commander points out.

For instance, when Hudson Health Plan conducted a barrier study to find out why its members receiving Supplemental Social Security benefits were not making regular visits to primary care physicians or dentists, they found that the members knew about their benefits but they didn't think the visits were necessary.

As part of a Center for Healthcare Strategies workgroup to improve services for members with disabilities, the New York health plan instituted incentives for members to make primary care and dental visits and incentives for the providers to forward information about the visit to the health plan, says Margaret Leonard, MS, RN, C, FPN, CM, vice president of clinical services.

The pilot was so successful that the health plan rolled it out to its entire population.

A key component of the program is orientation by bilingual case management assistants trained in dealing with mentally ill populations, who make orientation calls to the members. Case managers follow up to encourage the members to seek preventive health and dental care, Leonard says.

Montefiore Medical Center's Care Management Organization (MCO) in Yonkers, NY, uses remote monitoring equipment to leverage the resources of its case managers who manage the care of patients with congestive heart failure.

Patients weigh themselves, then answer a set of questions each day. The case manager is alerted if the data show that the patient's conditioning is worsening. This helps the case manager determine which patient needs to be contacted that day.

The remote monitoring equipment allows a case manager to monitor the care of 130-150 patients instead of carrying the typical caseload, says Anne Meara, RN, director of medical management at the care management organization.

"There are always more patients than nurses who are doing complex case management. Nurses can manage only so many patients and do a good job. We have to get better at knowing who needs to be managed today, and that is what remote monitoring does for us. It alerts us to which patients need attention," she says.