DM program keeps AIDS patients out of hospital

One-on-one education is the key to success

An intensive one-on-one case management program helps people with AIDS stay adherent to their medication regime, avoid hospitalizations and emergency department visits, and learn to self-manage their disease.

Positive Healthcare Florida, the disease management program of the AIDS Healthcare Foundation, is the only National Committee for Quality Assurance-accredited disease management program for HIV-AIDS in the country. The program received a score of 98.4% out of a possible 100% during the survey.

RN care managers with extensive HIV-AIDS expertise oversee the care of 10,000 Medicaid patients with AIDS across the state of Florida.

"We've been successful because of the intense one-on-one and face-to-face work with the patients. The nurses follow them closely and develop a wonderful rapport. The core of our program is education and one-on-one coaching to improve the patients' quality of life and to keep them out of the emergency department and out of the hospital," says Gene Bundrock, MS, RN, CCM, statewide director for AIDS Healthcare Foundation's Positive Healthcare Florida.

The field-based care managers work out of their homes and manage the care of patients in the counties in which they live. They work closely with the patients' physicians, often accompanying patients to their office visits, and working with them to coordinate care.

"Positive Healthcare takes a different approach to disease management. We do a lot of face-to-face assessments. The care managers get to know the provider and work closely with them. They meet with social service agencies in the community and incorporate them in the plan of care," says Donna Stidham, chief of managed care for the AIDS Healthcare Foundation.

Publicly supported patients with AIDS present a challenge to providers. They are poor. Many don't have telephones. They often live with relatives and move around a lot, Bundrock says.

The program uses representatives from the community who help find patients and call the care manager. The representative makes an appointment for the patient with the care manager, who sees him or her within three days.

"Our care managers will meet with them anywhere — the home, the doctor's office, in a restaurant, or even under a bridge. We'll go anywhere the patient feels comfortable and where their confidentiality won't be breached," Stidham says.

When new patients are identified for the program, the nurse contacts them and makes an appointment to see them, preferably at their home.

"It helps the nurses manage the care if they can see their patients in the home environment and become aware of their living conditions. Some don't have electricity. Others may not have a refrigerator or cooking facilities. It helps us tailor a care plan when we can see firsthand what the patient is facing," Bundrock says.

Patient assessments

The care managers conduct an extensive assessment that categorizes patients by severity level and acts as a guideline for the number of interventions the patient received. They determine the patients' needs and barriers to care, such as transportation, and get a consent form allowing them to go into the physician's office and examine the patient's medical record.

"These patients are not good historians on previous hospitalizations. They may know they had a cough but not whether it was pneumonia. Our nurses examine the medical record to find out what we need to know to manage the disease," Bundrock says.

The care managers zero in on patients with a high acuity level who are frequently hospitalized, not adherent to their medication regime, and are substance abusers.

"Once the nurse has seen the patient in person, some of the work can be done telephonically. She might not need to see patients every month if they are doing OK, the lab work looks good, and she knows they are being adherent with their medications," Bundrock reports.

The disease management nurses remind patients if they have physician appointments, check to see that the appointment has taken place, and visit the physician's office to review the chart. They give the patient a pillbox to help them organize their medications and stress the importance of taking the medication until the physician discontinues it.

Because confidentiality is an issue with AIDS patients, Positive Healthcare mails AIDS-related educational materials only to patients who have given their permission. Otherwise, introductory and follow-up letters are very generic.

The care managers know their community well, often serving on local health planning councils. They know the practitioners in the community and know how to guide their patients through the complex medical system to get help.

The care manager can mine the database for claims data and talk to the physician if a patient is making frequent trips to the emergency department.

"These patients have a lot of mental health issues as well. Depression is a huge problem, and many are on psychiatric medication. Physicians can't get the patients interested in caring for themselves until their mental status is stable," Bundrock says.

Dental care is another problem for AIDS patients on Medicaid.

"The state doesn't pay for dental work of any kind, but Medicaid patients still get toothaches. We try to get them access to dental care so they won't go to the emergency department or hospital with an infection that's the result of a dental problem," he says.

A team of nurses and an LPN care partner manage the care of the population in each area. The LPN takes care of telephone calls and other reminders for patients who are at severity level 1, allowing the care manager to concentrate on the more complex patients who are in and out of the emergency department, helping them avoid admissions.

For instance, AIDS medications often cause adverse reactions until the patient gets used to them, causing trips to the emergency department for pain and nausea. The care managers encourage them to try alternatives.

Working with physicians

"Now instead of going to the emergency department when they start a new medication and have cramps, they call the care manager who helps them understand that it might be a side effect of the medication. They suggest that they use an over-the-counter medication rather than going to the emergency department," Bundrock explains.

The care managers work closely with the physicians and nurses in physician offices to make sure that the patients are getting the recommended care. They refer any problems they spot to Bundrock or the medical director, who contacts the physician and educates him or her about evidence-based guidelines for the treatment of HIV-AIDS.

Positive Healthcare holds six educational programs a year in each region, informing physicians about the latest information from the scientific community.

"We stay up on new treatment regimes and make sure the physicians know about them. A bad regime can have a bad outcome, which in turn can cost hundreds of thousands of dollars," Bundrock says.

Physicians in the AIDS Healthcare Foundation's disease management programs work with the physicians who care for the patient.

"They don't want to interrupt the physician-patient relationship but they do want to enhance the physician's access to knowledge about the condition," Stidham says.

In California, the AIDS Healthcare Foundation began operating one of the first Medicaid managed care programs specially designed for people with AIDS in California in 1995. The foundation has received approval to operate a Medicare Advantage plan, allowing the patients to get their drugs through Medicare Part D.

The Medicaid program covers the sickest of the sick, only people with AIDS. HIV-positive patients are not eligible.

The state of California compares the foundation's costs to the fee-for-service Medicaid program and splits the savings with the foundation on a 50-50 basis.

"Our patients have always had better outcomes, shorter lengths of stay, and less cost than the fee-for-service patients," Stidham says.

Patients in both the Medicare and Medicaid programs are assigned an RN case manager who has HIV expertise. All of the primary care physicians and specialists in the network have experience working with people with AIDS, and the formulary is designed with people with AIDS in mind.