Program helps HIV-AIDS members over obstacles

Disease takes precedence in CM programs

When the state of New Jersey mandated that health plans establish a case management program for their publicly insured members with HIV-AIDS, Horizon-NJ health plan went a step further and put a nurse who is experienced in HIV case management in the position.

"It’s not just a matter of putting a nurse in a seat when you develop a program of this caliber and scope. You need to have the right professional in charge, someone with expertise in managing the care of people with infectious diseases. We felt that to increase quality of care for these members, we needed someone with more expertise," says Pamela Persichilli, RNC, director of clinical operations for the Trenton-based health plan.

The plan provides case management for approximately 1,300 members, about 60% of whom are HIV-positive, while the rest have AIDS.

Patricia Havercamp, RN, BSN, senior case management consultant, coordinates the care of all members with HIV-AIDS, even if they are eligible for another disease management program.

"If a member has comorbidities, the HIV program takes precedence. They may get the diabetes education piece from the diabetes program, but their care is coordinated by the HIV-AIDS case manager," says Cathy Kelly, RN, BA, CMCN, CPUM, manager of utilization management.

When one of the HIV members becomes pregnant, her care is coordinated by the high-risk obstetrics case manager, who works very closely with the HIV case manager.

"We have a very robust multidisciplinary team that meets every two weeks to discuss the patients with comorbidities," Persichilli says.

The purpose of the care management program is to educate the members about their disease, to identify any barriers to care, and to encourage the members to be compliant with their medication regime so they will avoid emergency department visits and hospital admissions, she explains.

"The whole mission and philosophy of our organization is to expand our partnerships with community organizations in order to inform our members and overcome obstacles to care. A population that is publicly insured has so many obstacles that they don’t know where to get help," Persichilli says.

Horizon-NJ health plan does everything it can to ensure that its members with HIV-AIDS get the care they need, including allowing an infectious disease specialist to serve as the primary care physician for this population.

The reason is twofold: AIDS is such a complicated disease that patients really need a specialist to provide their care. In addition, the patients are more likely to go to the infectious disease clinic than to another provider.

"In the case of these members, the specialist becomes the primary care provider. They get their flu shots and other care at the infectious disease clinic. This is not a population that will go to multiple places to receive care," Kelly says.

Havercamp collaborates with the infectious disease physicians, social workers, and case managers in the infectious disease clinic, working with them to develop a treatment plan and reinforcing what the patients hear at the clinic.

"Trying to manage HIV-AIDS without a connection to an infectious disease specialist is almost impossible. It has to be a partnership, and you have to make an effort to build a close relationship with the specialist," Kelly says.

When new members with HIV or AIDS are identified, the case manager gets in touch with the member by telephone, educates him or her about the disease and treatment options, and encourages the member to see an infectious disease specialist.

The program is part of Horizon NJ Healthcare’s longitudinal case management program, which stratifies members into categories based on the disease process.

Havercamp uses an assessment tool and utilization data and stratifies members based on their needs.

For instance, someone who is in and out of the hospital frequently would be a high-risk patient and would receive intensive case management, while someone who is compliant might get an occasional telephone call.

A newly diagnosed AIDS patient is stratified to a higher level until the case manager feels the member understands the disease and the treatment regime.

As a general rule, the case manager talks to members monthly, but members who are in the most severe level may receive a phone call once a week or even every day.

The case manager works with the infectious disease clinic on a treatment plan that both of them reinforce. The most important component is encouraging the members to be compliant with their medication regimes, Kelly adds.

"The clinics really like having our case manager reinforce what they are saying to these patients. I just got a letter from the HIV care manager at an infectious disease office saying that we are making the physician’s job easier by helping our members learn to navigate the system," Persichilli says.

The clinics reciprocate, helping the case manager get in touch with the members and encouraging their patients to work with the case manager.

"Sometimes members don’t want to talk to us, particularly when they are newly diagnosed. We see the infectious disease clinics as our go-between because it’s one place that the members do go," Kelly says.

The health plan is promoting education of people who may be infected and not know it.

"The biggest increase in the AIDS population is among heterosexual females. We’ve had several healthy young women who ended up in the hospital in critical condition because they didn’t realize they had HIV and got an opportunistic infection," she says.