CMs, DMs collaborate to coordinate care for Medicare Advantage members

Software system integrates support, avoids duplication

At a health insurer in the northwest mountain state region, case managers and disease managers work hand in hand and share an electronic care management software system that allows them to seamlessly manage the care of their Medicare Advantage members.

The health plan implemented a new software system in May that allows the disease managers, the case managers, and the behavioral health staff to operate on the same platform.

"We have easy access to information on any member. This enables us to integrate the support that we offer our members and avoid duplication," says Sharon Arneson, RN, CCM, manager of case management and disease management.

Before the new software was implemented, the case managers and disease managers communicated by telephone and e-mail.

"Now, we can move between the programs to meet whatever is the need of that member at that particular time," she says.

The health plan's goal is to ensure that members get the right services at the right time and in the right place, says Doug King, MSW, LCSW, MBA, manager of supplemental programs.

Members can be in disease management and have a case manager at the same time, he adds.

Case managers provide complex care management services for members who are in the hospital or a post-acute facility; who have an illness or injury that requires a complex treatment plan; or who have been diagnosed with serious medical conditions such as cancer and need help choosing the best treatment options, King says.

"Members don't have to be chronically ill to qualify for case management. They just have to be in a situation in which they need a health care advocate," King says.

Regence offers disease management programs for individuals with congestive heart failure, chronic obstructive pulmonary disease, asthma, diabetes, and coronary artery disease.

They screen these members for depression and anxiety since there are high comorbidities for people with chronic conditions and may refer them to the health plan's behavioral health team.

If a member in disease management is having an acute issue or other complex needs or ends up in the hospital, the disease management team calls in a case manager.

"Sometimes we will co-manage the member, or the disease management nurse will just be in a holding pattern while the case manager works with the member," he says.

At the same time, when the case managers are working with members with complex needs and determine that they have conditions covered by the disease management program, they make a referral to the disease management team.

The disease managers and case managers also can refer members for health coaching if they need to lose weight, stop smoking, or need help with other lifestyle issues.

"If members need to be co-managed, having all the information on one platform makes it much easier. When the nurses or behavioral health specialists document in the case notes, the disease managers have instant access to it. We can see the treatment plan, what goals have been set, what interventions have occurred, and when the case manager has contacted the member last," Arneson says.

Members also like the process since they no longer have to repeat the same information to the case managers that they gave to the disease manager, she adds.

Members are referred to case management when they are hospitalized or have an emergency department visit and from the company's utilization review nurses when providers request certain types of complex services. In addition, members may refer themselves for case management, or family members may refer them.

"If it's a self-referral or a family referral, they receive automatic approval for the program. If members request it, we will enroll them and help them with whatever issue they have," King says.

The health plan also uses predictive modeling to identify members who could benefit from case management.

For instance, members who have an orthopedic issue and a history of falls would be triggered for case management.

"We would make sure they have the right durable medical equipment and that they receive occupational therapy or physical therapy if appropriate. Our purpose is to reach out and make positive interventions to prevent future health care problems from emerging," King says.

When members are hospitalized, the Regence case managers work closely with the hospital utilization staff to ensure that the members get the care they need, he adds.

"We use Milliman Care Guidelines to examine what condition the member has, what care is being provided, and to actively and assertively assist in driving the care," he says.

For instance, if a member has a pacemaker installed on Friday and is being kept in the hospital over the weekend for monitoring, the case manager intervenes if evidence doesn't show that the patient needs to be monitored in an acute care setting.

"In this case, we would make sure that the member needs continuing acute care and isn't just sitting in the hospital over the weekend. It's a matter of ensuring that our members are getting the right care at the right time," he says.

They conduct concurrent reviews to ensure that the patients are receiving the services that they need and are in the right level of care.

"We look at whether a member could get the care he or she needs at a skilled nursing facility or a long-term acute care hospital. If we can get the member the right care in the best setting, we can help lower their out-of-pocket expenses or copayments," he says.

Case managers interact with members and their families as well as providers.

Explaining continuum of care

"We try to address the issue of continuum of care, explaining to the family why members are at the current level of care, and when and where they should receive care in the future. We work with the discharge planners at the facility to help the member transition between levels of care" King says.

Often the case managers educate family members about the various levels of care, explaining why patients need to be discharged from the acute inpatient setting and helping them understand what kind of care they will receive at the next level of care.

"We explain why the member needs to go to the next level of care and show them their financial responsibility if they continue to stay in a facility that Medicare won't pay for. We support the hospital decision to discharge when the chart shows that the patient is ready to go. We don't want the hospital discharging people too early because they come right back," he says.

The case managers advocate for the members with the clinical staff in the hospital to ensure that the member receives recommended care.

If a member is experiencing frequent readmissions for the same condition, the case managers intervene and conduct an assessment to determine the cause. It may be that the member doesn't understand the treatment plan or is unable to follow it and needs help from a health coach or a disease management nurse. Or the case manager may find out that the members didn't receive the post-acute services that were prescribed or that they were inadequate, or, in some cases, the patient was discharged from the hospital too soon.

"We try to be as proactive as we can. The more we are involved, the more it's a win-win effort. If we can help members avoid future episodes of care, it reduces health care costs, reduces their out-of-pocket expenses, and improves the quality of life for our members," King says.

The health plan uses a data mining tool to identify members who are eligible for the disease management program and uses a three-pronged strategy to help them manage their conditions.

Low-risk members are those with chronic conditions who are managing well with no gaps in care and no inpatient stays or emergency department visits associated with the condition or disease.

They receive a welcome letter along with a brochure describing the program and regular educational newsletters. The low-risk members also are offered the opportunity to opt in to the program if they think they need support from a nurse. A low-risk member who chooses to opt in to the program might be someone who is concerned because of changes in his or her blood sugar level or needs support to get on a diet and exercise program.

"Our role is to help the members set healthy lifestyle goals and to provide support for the physician's treatment plan," Arneson says.

Members at moderate risk have a gap in care, such as not receiving a cholesterol screening or a hemoglobin A1c test.

"Every quarter, we have campaigns set up that focus on members with care gaps. We encourage them to talk with their provider about evidence-based care guidelines to ensure that our members receive the full range of services to address their health conditions," she says.

All of the disease managers are RNs and have earned the Certified Chronic Care Professional (CCP) designation.

When a member agrees to participate in the disease management program, the disease management nurse completes a disease-specific assessment over the telephone. The assessment includes information about the member's condition, knowledge of his or her treatment plan, and risk factors.

For instance, if the member has asthma, it's important for the nurse to know if he or she smokes, something that doesn't readily show up in claims data.

They screen all members for depression and coordinate their care with the behavioral health team if needed.

The disease management program for high-risk members is individualized. The frequency with which the nurses contact the members depends on the members' needs and preferences.

For instance, if a member has experienced an exacerbation in his or her condition or has started on new medications, the nurse may call in frequently. Then, as goals are met, the nurse contacts the member every few weeks, then every few months.