CMs guide members on end-of-life decisions

Insurer’s initiatives include education for staff

When case managers at Highmark Blue Cross and Blue Shield bring up advance directives with their patients, they are well prepared.

The insurer has developed a comprehensive plan to increase awareness of advance care planning by working with community groups, educating health care providers, and guiding members through the process.

"We wanted to respect our members’ choices regarding advance care planning, whether they wanted full treatment or limited treatment. We want to make sure our members know that there are options in a terminal illness. Our goal is to avoid last-minute indecisions," says Judith Black, MD, senior products medical director for the Pittsburgh-based insurer.

Before Highmark Blue Cross and Blue Shield started its advance care planning initiatives in the summer of 2000, the insurer created an educational process for the staff.

Highmark developed a training video for case managers and care managers to help them talk to members about advance care planning and the difference between comprehensive planning and just having advance directives in place.

The video includes role-playing by staff members showing scenarios between case managers and their clients when end-of-life issues are discussed.

The health plan did an assessment of case managers’ comfort level with end-of-life topics before and after viewing the video. The comfort level increased after the video.

When the case managers meet for their weekly case presentations, one always is a case involving one of their highest-priority members for advance care planning.

When members are enrolled, the health plan sends them an advance directives packet and power-of-attorney form.

As they begin managing the care of the members, the case managers start discussions on the information in the packet.

Highmark Blue Cross and Blue Shield case managers are encouraged to stratify the members they work with into three levels of priority.

Those whose death within a year wouldn’t surprise the case managers, typically about 5% of the caseload, receive the highest priority. In these cases, the case managers work to ensure that the patient’s end-of-life wishes are in order and understood by their health care providers and family members.

When they work with members who are older than 65 or have a chronic illness, the case managers encourage them to have advance directives and a health care surrogate.

The rest are the members who are relatively young and healthy.

The case managers have been trained to find out what the patient and family understand about where they are in the disease process.

If they are not sure, the case managers talk with the patient’s physician to make sure everybody is on the same page, Black says.

The health plan’s case management documentation software includes a template on which case managers can check off whether a member has advance directives. If other case managers get involved in the patient’s care, they know whether to approach the subject.