Member-driven case management/disease management system pays off

Plan takes a proactive approach to members’ health

When Blue Cross Blue Shield of Michigan created its proactive case management and disease management program, the Detroit-based insurer looked for every opportunity to interact with members, in addition to maximizing the traditional disease management and case management strategies.

BlueHealthConnection, a new program launched in May 2002, integrates case management, disease management, and the health plan’s 24-hour nurse line, and provides a seamless system for members.

"We call it a program without walls. It’s fully integrated, and the patients may move back and forth seamlessly through the levels," says Jann Caison-Sorey, MD, MHCA, FAAP, medical director for the program.

Like many insurers, Blue Cross Blue Shield of Michigan found that 10% of its members utilized the majority of case management time and accounted for the majority of benefits usages, he says.

The plan set out to create a program that would provide coordinated care to all members as well as identifying members who ordinarily might fall through the cracks.

The BlueHealthConnection integrated case and disease management program concentrates on four conditions:

1. diabetes;

2. ischemic heart disease (encompassing all diseases that involve narrowing or injury to the vascular system involving heart disease);

3. congestive heart failure;

4. asthma.

The plan is adding cancer management and depression screening this year.

"The four conditions alone account for a significant amount of cost among any population. Many of them are poorly controlled. If the members are not getting the right care interventions, the likelihood is they are not going to have an optimal outcome," Caison-Sorey adds.

Before the program was redesigned, the case management department was reactive, coordinating with the pre-certification staff, intervening when patients had long lengths of stay in the hospital, handling discharge planning, and working with the benefits department to get patients who needed it to alternative levels of care, adds Michelle Fullerton, RN, CCM, manager of integrated case and disease management.

"We found that we helped a lot of people but still were very reactive," she says.

Once the patient got home, the case managers backed out of the case and responded only if the patient called them.

"We were letting go of patients who were complex diabetics or had congestive heart failure and who could benefit from additional interventions. We felt we needed to take a more proactive approach instead of being reactive," Fullerton says.

The health plan has had disease management programs since it launched a pilot program in 1994. "Our traditional disease management criteria were very selective. They chose the highest-risk patients. Ours had a very good success rate, but we felt there were other missed opportunities in our overall population," says Jeff Powell, MS, MA, manager of outcomes measures and evaluation.

The new program targets members earlier in the disease state process and uses proactive interventions rather than taking the traditional case management approach.

The innovative components include:

  • When members call the BlueHealthConnection nurse line for any reason, the nurse who takes the call fishes for any health problems or questions the members or their family may have and gives advice and information on the spot, as well as referring those who may need follow-up to the case management/disease management department.

The nurse line staff are trained in fishing techniques to identify any other health care needs, problems, or concerns that members or their family may have. "We are trying not to miss any opportunity to educate and care for our members," Fullerton says.

For instance, a member may call in to ask when a child needs an immunization. The nurse may talk to him about his own health and find out that the member recently has been diagnosed with diabetes. When the nurse finds out the member has diabetes, she does a diabetic assessment and enrolls the member in the diabetes program. The case managers follow up with a phone call and continue diabetes disease management interventions.

Another example: A member calls in asking about coronary artery disease. When he talks to the nurse, he mentions that his wife had been diagnosed with cancer and was not coping well. The nurse notifies a case manager who calls the couple to discuss the cancer.

"We have four diseases that we focus on, but we are open to handling anything that we find out the member needs," Fullerton says.

  • Members who are identified by predictive modeling as being at risk receive a letter from the health plan, explaining the program, then a follow-up telephone call from a case manager.

When Blue Cross Blue Shield of Michigan started the BlueHealthConnection program, the case managers cold-called any member who met the criteria for the program. Now, they send out an introductory letter before the case manager calls.

"We didn’t find cold-calling very successful. The members wondered why their insurance company was calling. Now they are less suspicious and much more appreciative that a nurse is calling to work with them," Fullerton says.

"Having a health insurer doing something for them other than paying claims was not in the realm of their expectations," Powell says.

  • When a member is hospitalized for any reason, if he or she has been identified by predictive modeling, the case manager follows up the hospitalization with a telephone call.

"After we fixed the cold-call scenario, we found that if we linked our call with a recent inpatient hospitalization, the member would be even more interested in working with us," says Fullerton.

The plan found that regardless of the reason for hospitalization, the experience left the members more interested in learning about and improving their health.

The case managers call any member who has been hospitalized, even if it’s not for his or her chronic condition and even if the gap score and risk scores might not typically warrant a telephone call. For instance, if a member who is at risk for diabetes is hospitalized for a hysterectomy, she gets a call from the case manager, who talks with her about getting her diabetes under control.

"We know that when members have had a brush with the hospital, they feel more mortal at that point. Even though they may have had a diagnosis and know the consequences for a long time, people become more serious about their health following hospitalizations," Fullerton says.

Tying the interventions to recent discharges from the hospital has proved to be an excellent way to get members to participate in the program, she says.

The program has a high success rate. More than 80% of members targeted engage with the plan for some condition. After the plan started sending out the letter, there was a dramatic increase in the number of members who were willing to participate, Powell says.

Member satisfaction has improved. In the plan’s annual satisfaction survey, 85% to 90% of members expressed satisfaction with the program, 22% of members who talked to a nurse reported adopting a lifestyle change as a result of the intervention, and 67% indicated that their relationship with their provider improved as a result of interaction with a BlueHealthConnection nurse.

Although it’s too soon for any definitive data on return on investment, the health plan’s preliminary analysis indicates that the program is highly successful, Powell says.

The statistics on members’ compliance with hemoglobin A1C and lipid testing guidelines has improved.