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Guiding seniors through EOL
Seniors covered by BlueCross BlueShield of Tennessee's Medicare Advantage plan are guided through the end-of-life (EOL) processes and are being empowered with the education, resources, and assistance they need to make their own decisions about what kind of care they want to receive at the end of life.
The Chattanooga-based health plan end-of-life planning program received a bronze award in fall 2010 at the Best Practices in Health Care Consumer Protection and Empowerment awards ceremony from URAC, a Washington, DC-based organization that promotes healthcare quality through its accreditation, education, and measurement programs. (formerly known as Utilization Review Accreditation Commission.
The program began in 2009 after the health plan started its Medicare Advantage program in 2006, says Alice Greer, RN, BSN, CPHQ, quality research analyst in quality management. "As we worked with the Medicare population, we realized that end-of-life concerns are a big issue. We found that even though some of the members knew they were facing a potentially terminal illness, they hadn't thought about end-of-life plans, or if they had, they didn't have a legally appropriate form or had not shared their wishes with their family or their physician," Greer says.
At the same time, the insurer determined that many staff members were uncomfortable initiating a conversation about EOL considerations and needed education to learn how to approach members about their choices. "We looked for ways to assess our Medicare population to identify people who needed the program and to aid the case managers in bringing up the subject with members and leading them through the process," Greer says. (For more information on the assessment process, see story, below.)
The case managers who work with the Medicare Advantage members have been trained on how to approach the subject and have information at their fingertips to educate the members. The health plan also collaborated with the non-profit Tennessee End-of-Life Partnership and sponsored a daylong educational program for case managers and the health plan's providers.
When seniors sign up for Medicare Advantage, the health plan sends them the health needs assessment. They can return it by mail and have it scanned into the computer program, or they can call and complete the assessment over the telephone.
Referrals come from the health needs assessment, from the utilization management department, from claims data that show members with multiple hospital admissions, and from the health plan's predictive modeling. The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage to conduct an initial health needs assessment. "We tweaked our assessment and configured our computer system so it would automatically send out a referral when someone had a condition that indicated they might benefit from an end-of-life discussion," Greer says.
Medicare Advantage members who are referred to the program are asked if they have EOL plans and if they would like to discuss the subject. Those who meet the criteria for needing immediate EOL support are offered a more intensive care plan, Greer says. Criteria for the intensive care plan include debility, failure to thrive, cancer patients with a terminal diagnosis or uncontrolled symptoms, advanced heart disease patients, advanced pulmonary diseases, dementia, end-stage liver or renal disease, and neurological disorders.
The utilization management department has a trigger list of criteria. If someone calls to obtain approval for a procedure and the patient falls into one of the diagnosis categories, those nurses are trained to send a referral, she says. Outreach calls are then made to all members who are eligible for the intensive care planning program. The services the health plan offers are explained the services, how the EOL planning will occur, and how they can be empowered to make their own decisions.
EOL program assessment process
If senior members consent to participate in the BlueCross BlueShield of Tennessee's Medicare Advantage end-of-life (EOL) plan, a thorough assessment is made that includes their current health status; their present functional status; resources they have; their caregivers; their understanding of their current level of health, diagnosis, and prognosis; information on their socioeconomic status; and any educational or language barriers.
The Medicare Advantage staff includes two social workers who help people complete the forms over the telephone or, if the member prefers, will meet with them at the health plan's Silver Life Center in Chattanooga, TN. Consent to notify the member's primary care provider is then obtained to collaborate with the physician as well as the caregiver so everyone is on the same page.
One of the goals of the EOL program is to overcome the negative impression many older people have of hospice care by educating them. Some members aren't aware of the hospice benefits they have. Others don't take advantage of them because of their perception of what hospice means, says Alice Greer, RN, BSN, CPHQ, quality research analyst in quality management.
"Length of stay in hospice is incredibly short with our Medicare population," Greer says. "If somebody doesn't get into hospice until the last two days of their life, they've lost the opportunity to increase the quality of life, have gone through unnecessary procedures, and increase the stress on the family. Knowing about hospice and what it means saves people a lot of panic-mode trips to the emergency room for interventions and makes them feel more in control."