Bipolar DM helps with medication adherence

Program reduces hospitalizations

WellPoint Inc.'s disease management program, designed to improve care for members with bipolar disorder, reported a 22% increase in medication compliance and a 14% decrease in behavioral inpatient services for members during a recent outcomes revaluation.

The program started in 2004 in Colorado and was expanded into California, then into other Anthem Blue Cross Blue Shield programs in Ohio, Indiana, Kentucky, Illinois, Wisconsin, Missouri, Georgia, and Nevada, says Sue Smith, PhD, RN, CCM, medical manager for WellPoint's bipolar condition care program.

"We have expanded gradually as we found that we were successful with increasing medication compliance. We are always looking at ways to help individuals who have medical problems and coexisting psychiatric issues. It's a win-win situation. The program results in substantial savings as well as giving members a better quality of life," says Martin Glasser, MD, medical director of the program.

The goal of the bipolar condition care program is to help members with bipolar disorder achieve their optimal health through education and care management support.

"When we engage patients, we find that lack of medication compliance is a big issue. Life stressors are another problem they face, and that's one reason we stay engaged. Stress often is the reason the patients get worse, and we work to help them with it," Smith says.

Medication adherence is a critical component in treating bipolar disorder because it impacts short-term recovery and long-term stability as well as the overall cost of care for the patient's psychiatric and medical needs, Smith points out.

Many patients with bipolar disorder do not take their medication as directed, she adds.

"It could be that they no longer feel they need it or they don't like the side effects and they stop taking them. In some cases, patients are challenged to afford their medications. Since those medications were helping stabilize them, they are likely to exhibit manic symptoms," she says.

Members who are eligible for the program are 18 years of age or older with a diagnosis of bipolar disorder and are being treated with medication.

Patients also are identified for the program through clinical reviews and pharmacy reports. In addition, members can call the health plan's resource center and be referred to the program when they need help in finding therapy or need other support.

"There are multiple points of entry into our system. We do data mining as well as working extensively with the medical management team and behavioral health utilization team. We see many members who are being discharged from the hospital with bipolar illness who require case management," Smith says.

The program is voluntary. Members who agree to participate in the program are stratified based on the severity of their condition after screenings for acuity, depression, and past history.

Each member is assigned a case manager, an experienced, licensed therapist with a master's degree or higher. The case managers make appointments to call the member on a periodic basis.

If the member's bipolar illness is in a high state of acuity, the case manager may call on a weekly or even a biweekly basis.

Once the patient's condition is stabilized, the case manager may call only once a month, then every few months, Smith says.

"We try to identify them early on when they are first diagnosed and send them materials explaining the condition and what effect it could have on their lives. Then we call them and offer assistance," Smith says.

In a typical scenario, someone with bipolar disorder goes into the hospital completely stressed, gets treatment that helps get the condition under control, and is released back to the community without the services they need, Smith says.

The bipolar condition care program gives them the support they need to adhere to their medication regimen and stay stable, she adds.

"We make an outreach call to anyone who is discharged with bipolar illness as the primary diagnosis to see how they are doing and to work with them so they'll be adherent to their medication regimen. We help them get established with a psychiatrist so they can get the treatment they need," Smith says.

People who are newly diagnosed with bipolar disorder often test the waters and stop their medication to see if they really need it, Glasser says.

"Then they cycle into a manic state and need to be hospitalized. When we are engaged with them, we can tell when they are starting to act a little different, then find out that they stopped their medication and get them to restart it," Glasser says.

The case managers work with their clients to problem-solve and focus on medication adherence. They connect with the member's health care providers to make sure they are getting the services they need.

The same case manager works with the member as long as he or she stays in the program.

"The relationship that the member builds up with the case manager over time is one of the biggest factors in the success of this program. When individuals with bipolar disorder experience a medical crisis, family problems, or an emotional crisis, they tend to regress and end up in the hospital unless they have help and support. Our case managers get to know them and help with stresses in their lives that could cause an exacerbation of their condition," Glasser says.

The case managers work with the patients to solve the problems that prevent them from taking their medication.

"We want to reduce hospitalizations among these patients, and that means working closely with them to keep them stable," she says.

Medications for bipolar disorder can have many side effects, including weight gain, acne, and loss of sexual function, Glasser says.

"The medication makes patients feel better immediately when they are used according to guidelines, but the side effects can be insidious and get worse the longer the patients are on it," he adds.

When the case managers pick up a concern about the medication or side effects, they empower the member to talk with his or her psychiatrist or primary care physician about it, or if the member requests, the case manager or Glasser calls the physician to discuss the problem.

If the member wants to talk to the provider but is not sure what to say, the case manager sets up a conference call.

"We also work with the physicians to clarify situations we consider to be a safety issue. Multiple providers don't always communicate. We try to engage every provider who is treating the patient and keep them informed about what the team is doing," Glasser says.

For instance, the bipolar team informs the psychiatrist of what medications the primary care physician has prescribed and vice versa. If the patient is starting to drink alcohol, they make sure the psychiatrist is aware of it. The bipolar team keeps the primary care physician and any other treating physicians informed about the patient's progress and problems.

"Many programs collaborate only with the therapist. We try to be all-inclusive and work with the entire treatment team. Our program is unique because we try to engage all physicians and therapists involved with the patient in coordinating care for the member," Smith says.

The case managers in the bipolar program work closely with their counterparts in disease management to coordinate care for patients with bipolar disorder as a secondary condition.

"We have a collaborative, holistic approach with our disease management and medical management programs. We work together with the nurses in the other program to ensure that the members receive all the help they need," Smith says.

For instance, if a member in the diabetes disease management program is identified as someone who has had bipolar disorder, the disease manager will make a referral and a case manager from the bipolar program will contact the member and complete an assessment to determine if he or she needs help.

The case manager makes an outreach call to determine what issues the patient is having that make it difficult to get his or her prescription refilled. It may be that he or she is having financial problems or has not seen the physician for a new prescription, she adds.

The bipolar team holds rounds each week, during which the case managers bring up challenging situations and get peer support.

"There is a lot of ongoing monitoring and discussion going on to ensure that the patients are getting everything they need to learn to manage their disease and improve their quality of life," Glasser says.

The program is very popular with participants and always receives high scores on member satisfaction surveys, Glasser reports.

"We have multiple success stories from our members and from the case managers. The members really like the program and they're quite vocal with their compliments. Our metrics support a significant reduction in the cost of care for the members by reducing hospitalizations, readmissions, and by continued engagement and coordination with providers," Glasser says.