Program provides seamless case management
Program provides seamless case management
Health plan identifies gaps in recommended care
By combining its individual disease management programs into a member-centered system and reminding members of gaps in recommended care, Buffalo-based HealthNow New York helps members assume responsibility for managing their conditions so they can stay healthy and out of the hospital.
In 2005, the health plan revamped its disease management programs, creating a new program called the Health Management Program.
"When we had several disease management programs as separate entities, there was a lot of duplication of effort for people with comorbidities. Our goal is to make the program more member-centered and create a system that addresses all of a member's disease management needs with a single call instead of multiple calls," says Julie Kozlowski, RN, BA, corporate program coordinator, health services-case/disease management.
The health plan offers disease management for members with diabetes, depression, asthma, chronic kidney disease, and cardiovascular conditions.
The disease management staff are cross-trained on case management techniques; if members need more intense management or help with psycho-social issues, the same disease manager can continue working with them instead of handing them off to someone else.
HealthNow identifies its members for disease management through a predictive modeling tool that analyzes up to 24 months of claims data and projects costs and level-of-care needs based on claims compared to evidence-based medicine.
The program targets people who have disease exacerbations but who have not necessarily been hospitalized. For instance, a diabetic member may not be getting his or her hemoglobin A1c monitored or receiving dilated retinal examinations as often as he or she should.
"Our typical member in our Health Management Program is someone who is interested in learning to manage his or her disease but needs a little more direction," she says.
Members who are eligible for the program receive an outreach call from a nurse and a packet of information based on the nurse's assessment of needs. The nurses also screen members for depression and refer appropriate members to their primary care physicians or behavioral health specialists for follow-up.
The nurses call members as often as necessary to help them get their disease under control and to coach them on diet, exercise, and other ways to comply with their treatment plan and self-manage their conditions.
If the disease exacerbates, the disease management nurse steps up the interventions and provides case management, linking the member with specialty physicians or community services.
For instance, if a member's chronic kidney disease evolves into renal failure, the nurse may bring in a social worker to help arrange financial support and provide transportation for dialysis. The nurse may help the member find a nephrologist and work with the family to answer psycho-social needs.
In the case of the health plan's Medicare Advantage members who don't have family members or other support in the area, the nurse disease managers help members connect to community resources for transportation or help with medication or medical care. They also link them to services such as Meals on Wheels or support groups.
"Everyone is concerned about the Medicare drug benefit's doughnut hole. We direct them to agencies that can save them money," Kozlowski says.
The nurses work with the members on compliance issues and do whatever they can to help them adhere to their treatment plan.
For instance, the health plan provides a pillbox to help members who are on multiple medications organize their medicines.
In January, HealthNow began to offer members a new program called Personal Care Advance, which gives them the option to view their personal health records online and provides regularly updated customized content and links to pertinent Internet sites based on the member's preferences and his or her particular condition.
Bi-annual gap reports which remind members that they are missing a recommended treatment, procedure, or examination are a key part of the disease management program.
The health plan's predictive modeling tool also identifies gaps in care, which triggers a message that urges the members to receive the recommended care.
Since the program began in 2006, the health plan's diabetic members who have received gap reports have achieved a 12% increase in hemoglobin A1c tests, a 14.5% increase in retinal examinations, and a 27% increase in LDL cholesterol tests.
Mammography screening rates have increased by 14% since the health plan began sending out the gap reports. At the same time, influenza vaccinations have increased by 40%.
The health plan goes through its claims twice a year and comes up with individual gaps in care, including age-related gaps, such as a colonoscopy for people over 50; gender-appropriate gaps, such as mammographies and Pap smears; and evidence-based care for people with chronic conditions, such as diabetic foot exams. In the fall, all members with a chronic condition get a gap letter reminding them to get a flu shot.
The health plan sends a customized letter to the members with details on the missing examinations, tests, or procedures.
The reports compare the results of the members' most recent lab tests with recommended results based on evidence-based medicine, and encourage them to contact their physicians.
"The goal is to get them to take the letter to their doctor and discuss the care they are missing," she says.
The health plan also sends a roster to the primary care physician listing all the members with gaps in care who are their patients.
Since the gaps also correspond with Health Now's pay-for-performance program, the physicians can use the roster to help them achieve better compliance and qualify for pay-for-performance compensation.
"We've had a pay-for-performance initiative for many years. Now, we have an opportunity to add a second layer with the gap report that supports better achievement of pay-per-performance goals," she adds.
By combining its individual disease management programs into a member-centered system and reminding members of gaps in recommended care, Buffalo-based HealthNow New York helps members assume responsibility for managing their conditions so they can stay healthy and out of the hospital.Subscribe Now for Access
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