Program helps members stay independent at home

Multi-tiered program tailored to unique needs of seniors

Recognizing that seniors have a unique set of health care challenges, CDPHP has developed the Health Ally program for the Medicare population.

"Comprehensive management for the senior population involves taking into consideration all their medical issues and health care concerns. With seniors, you can't just get them to start a diet or exercise program. They may have problems with mobility or other issues that could impact their success," says Charlene Schlude, RN, CCM, manager of case and disease management for the physician-based, not-for-profit individual practice association (IPA) model HMO serving more than 400,000 members in New York and Vermont.

The CDPHP Health Ally program was created specifically for the Medicare population and takes into account the unique needs of older adults and tailors a program to fit the individual needs of the population, says Tracy Langlais, RN, vice president of resource coordination for CDPHP.

The program is a voluntary case management program for CDPHP's Medicare Choices members and their caregivers.

"One of the main goals of the program is to help the senior population maintain independence in their home. The program combines support, education, access to the health plan's benefits, and community-based services," Schlude says.

The plan offers wellness programs to appropriate members and refers those with chronic conditions to disease management programs. The health plan offers disease management programs for members with diabetes, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disorder.

"There is a program for every Medicare member, and we want to link every member to the appropriate program whenever possible," Langlais says.

The programs are closely integrated and coordinate with each other to meet all the members' needs, she says.

The disease management program focuses on helping members understand their chronic conditions and empowering them to talk to their physicians.

The case managers help the members learn to manage their diseases and to navigate through the health care system.

Other options for seniors range from no-cost wellness workshops on topics ranging from Tai Chi and yoga to healthy cooking and the Weigh 2 Be weight loss program.

When Medicare members enroll, a registered nurse or social worker case manager calls them and completes a detailed health risk assessment that screens them for chronic health conditions and pinpoints their needs for wellness education and case management. The case managers use the information from the assessment to develop a program to meet the member's individual needs.

"We added the health risk assessment a year ago. It's extremely valuable in helping us identify members who may need the various programs we offer. We also get direct referrals for disease management and case management and identify eligible members through claims data. The health risk assessment enables us to identify enrollees for care management programs before they experience an acute event. Our goal is to identify members who could benefit from care management as soon as they enroll," Schlude says.

If members are taking multiple medications, the case manager may refer them to the health plan's pharmacy program for help in understanding their medication regimen.

Members eligible for the case management program include those who have complex health care needs, are medically frail, have challenges in their home setting, or who may have less than optimum caregiver support. In some cases, a nurse practitioner performs a face-to-face assessment in members' homes.

In addition to providing the assessment to the case manager, the health plan gives a copy to the patient's primary care physician.

"We believe that collaboration between the case manager, the patient, and the physician is one of the most effective ways to help the chronically ill learn to manage their conditions," Langlais says.

The program is staffed by RN case managers and medical social workers who collaborate with members and their physicians to meet the individual's needs.

For instance, obesity can be an issue for elderly as well as younger members because being overweight affects chronic conditions. However, one weight loss program won't work for everyone, Schlude says.

"Seniors often have unique needs and challenges. When people have a progressive illness, one of their biggest challenges is to maintain their weight, particularly when they have limited mobility or dietary restrictions. We look at the unique needs of the population and tailor a program to fit the individual," she says.

For instance, the CDPHP Senior Fit Program offers Medicare enrollees the opportunity to join seniors exercise programs in the community, such as those provided by the Capital District YMCA, at no charge.

However, some seniors may have limited mobility or lack transportation and may need an exercise program they can do in their home, Schlude says.

"We tailored the program so they can learn in their homes how to manage their weight if that's what it takes. We may teach them something as simple as a chair exercise that gets them moving and increases their mobility. We provide as much guidance and support as we can to help them meet their goals," she says

"Wellness programs can benefit members of all age groups. A tailored program developed specifically for the Medicare population can have a positive impact on the health of older adults," Langlais says.

"It's important for someone older to learn to manage their conditions. We clearly see that older people with diabetes and other chronic conditions can stabilize their conditions by losing weight and complying with their treatment plan," she says.

The program emphasizes personal contact with the Medicare members.

"We continue to enhance our web-based educational tools to provide a variety of ways for members to access health information. For our Medicare population, telephonic outreach remains a primary means of communicating information and availability of services and programs. Human contact is very valuable, and it's a real opportunity for us to get feedback from our members," Schlude says.

Once Medicare members receive an initial call and develop a rapport with the care manager, they feel comfortable reaching out to their health plan for guidance navigating the health care system, she adds.

Any time a Medicare member is discharged from the hospital, the nurses in Health Ally call the patient to make sure he or she has a follow-up visit with a primary care physician.

"We know that when patients see a primary care physician within five to 10 days of discharge, it reduces the readmission rate. We also recognize that Medicare members may have problems making the appointments, so we work closely with their physicians to facilitate an office visit," she says.

Member satisfaction in the Health Ally program is extremely high.

"This program, in combination with our other programs, is very effective in stabilizing chronic health conditions, reducing health care costs, and enabling seniors to stay healthy at home. When we compare our inpatient admission rate and emergency department visits with those of the competition, ours are much lower," Langlais says.

"We look at continuation of health from the very healthy to end-of-life care. We want to keep people healthy and reduce risks for those who have identified chronic conditions. In addition, we strive to help those with chronic conditions receive the highest quality care," she says.

To make access to its programs easier, the health plan is launching a single-source referral line that physicians, members, or family members can call.

"We can assess individuals' unique health care needs on the spot and offer them the best program for their unique needs. This is a way to use our resources most effectively and meet the needs of our members. We look to assist our members and providers in gaining access to our programs, and by having a single point of contact, we can direct them to the program that best meets their needs," Langlais says.