Proactive interventions cut hospitalization rate dramatically

Program targets at-risk members

Since Harvard Pilgrim Health Care, based in Wellesley, MA, started its Health Advance care management system to intervene with at-risk members before they require intensive medical services, the hospitalization rate for members in the program has been cut in half.

In an eight-month period before the program started, members who qualify for Health Advance care management experienced a hospitalization rate of 16.73%. After the program was implemented in August 2001, members who participated in the program experienced an 8.32% hospitalization rate.

Based on the results to date, the health plan anticipates that Health Advance will deliver significant decreases in hospital days and a reduction in per-member, per-month costs of 20% to 25% for members participating in the program, says Liz Estabrook, RN, manager of care management for the health plan, which covers more than 800,000 members in Massachusetts, Maine, and New Hampshire.

Harvard Pilgrim Health Care uses a predictive modeling software application from Status One, a health management services company based in Westboro, MA, to identify at-risk members who typically have multiple chronic diseases and comorbidities and psychosocial needs.

"By intervening earlier, we can dramatically influence the health and well-being of this member group which, while very small in number, represents a high percentage of medical costs," Estabrook says.

The health plan has estimated that 0.5%-1% of the total membership accounts for 30%-40% of all inpatient days and 20%-30% of medical costs.

"We target members who are likely to have a hospital admission in the next year, based on their utilization history. These are members whose condition will get worse if they continue on the path they are on," Estabrook reports.

The original goal was to have a Health Advance care plan in place for at least 70% of the identified members. The actual figure is closer to 95%, with dramatic results, such as the decrease in hospitalization rates for members participating in Health Advance, adds Roberta Herman, MD, chief medical officer.

"Care for at-risk members is often uncoordinated and fragmented across multiple specialists, and they may not be well known to their primary care physicians. We work with our members’ care providers and families to create a patient-specific care plan designed to reduce the level of illness and improve daily living," she adds.

The Health Advance nurse care managers are highly experienced generalists who are trained to work with patients, no matter what their diagnosis.

They are assigned to members by geographic areas so they can be familiar with resources in the community and can develop a relationship with physicians.

The Health Advance nurse case managers work in tandem with the disease management team to coordinate care for patients who may qualify for one or more of the health plan’s disease management programs.

"Since these patients have multiple conditions, the Health Advance nurses take the primary responsibility for their cases," Estabrook adds.

For instance, if the Health Advance nurse care manager is working with a complex diabetic who needs a lot of education, he or she collaborates with the diabetes disease management nurse. The disease management nurse may provide the educational materials but leave the actual interventions to the Health Advance nurse.

A member who needs help managing only diabetes wouldn’t be in the Health Advance program.

"We definitely try to avoid having multiple people calling the same member," Estabrook says.

When the program started, a number of people already in the disease management program were shifted to the Health Advance program if they had multiple conditions.

"We evaluated the cases as we went along. If somebody was already in a close relationship with a disease management nurse, we might make an exception. We didn’t want to interrupt a relationship if the member was making good progress," she says.

The nurse case managers are assigned 10-15 new cases a month. They receive a complete utilization history, including what kind of hospital visits or outpatient visits the member has made and medications the member has been prescribed.

During the first call, the case managers get the patient history, determine how much the members know about their illness and medication, and answer any questions about the program or the members’ conditions.

"We work on building a relationship from that first phone call. The Health Advance care managers act as a coach and help the members feel comfortable and confident about managing their own disease," Estabrook says.

They work with the members to set goals and help them learn how to manage their own health.

The care managers collect clinical information from the member’s primary care physician and use the information to determine the member’s acuity level or potential for hospitalization in the future.

The acuity level determines how sick members are and how frequently the case manager will call them. The members are encouraged call the care manager in between calls if they have questions or concerns.

As the members build self-reliance and are able to take more responsibility for their own health care, the nurse case managers may move them to a lower acuity level and begin working with them less frequently.

"When they have their conditions more under control and moving in the right direction, we tell them that we feel like they can continue the process on their own," Estabrook says.

Members stay in the program an average of six to nine months.

When members are discharged from the program, the care manager lets them know that they can call any time in the future that they feel they need help.

If they are hospitalized again or their risk assessment changes, they automatically are put back into the Health Advance system.