Seamless program handles all levels of patient care

CM, DM, and guided self-management merged

Before Blue Cross Blue Shield of Michigan launched its BlueHealthConnection program, disease management nurses and case management nurses were in separate departments and never talked.

Now, the Detroit-based health plan takes a multipronged approach to patient care and, depending on patients’ needs and conditions, the same nurse that enrolls them into the program may help them manage their condition and coordinate their care in the hospital.

Case management now is integrated into a broader program that includes disease management and guided self management, says Jeff Powell, MS, MA, manager of outcomes measures and evaluation.

The disease manager/case manager may follow the patient through the hospital and back home, acting as a case manager, then start the disease management process again.

The disease management program is structured with interventions designed for members at all stages of chronicity or comorbidity.

"We wanted to broaden the pool of members in our disease management program and used predictive modeling to do that," Powell says.

Members who are identified through predictive modeling may receive literature in the mail or may receive a telephone call, depending on their gap and risk scores. All members who have been stratified as mid- or high level receive materials in the mail, followed up by a telephone call.

For instance, all diabetics get a postcard reminding them that the standards of care say they should get a hemoglobin A1C test. The reminder includes the number for the BlueHealthConnection line, staffed by nurses 24 hours a day.

"We’ve seen good success with our campaign to get our members to comply with nationally accepted guidelines," Powell says.

Guided self-management aids members

Members with lower priority scores who have been identified with a chronic disease but have a low risk of an acute episode are eligible for the plan’s guided self-management program.

Guided self-management includes members who are identified when they call into the 24-hour nurse line. If a member or someone in the household is identified with a chronic disease, the nurse asks if he or she is willing to participate in a program.

"We take the opportunity when it comes. We send them literature we have carefully selected to hit on every risk factor and give them an opportunity to educate themselves," says Jann Caison-Sorey, MD, MHCA, FAAP, medical director for the BlueHealthConnection program.

Newly diagnosed diabetics receive information on eye exams, weight control and exercise issues, and blood pressure control.

"We may give members with certain conditions an introductory call telling them they are eligible for the BlueHealthConnection program and telling them they can call about any chronic condition 24 hours a day," Powell says.

In those cases, the nurse case managers discuss the modifiable risk factors with members and tell them that if they follow them, they will have better outcomes. They encourage good compliance with medication and frequent visits to the physician.

The case managers establish a rapport with the members and guide them through the assessment process to identify their issues. For example, a member may not have had a hemoglobin A1C test or has been to the emergency department 12 times in a six-month period.

"We assess what the members’ issues are and by doing that try to educate them about their condition and what they need to do to keep it under control," says Michelle Fullerton, RN, CCM, manager of integrated case and disease management.

The case managers call these members at regular intervals throughout the year, depending on the severity of their condition and their needs. If a patient’s condition is extremely acute, the case manager may call as often as once a day.

"It’s very member-driven. If a case manager calls a congestive heart failure patient who is gasping, she’ll call the doctor’s office with the member. We get that involved," she adds.

When the case managers telephone the members, they find that many of them don’t fully understand their conditions or the long-term consequences of not managing them early on. "They often don’t understand that they need to manage their diabetes aggressively so they don’t go blind from diabetic retinopathy or lose their toes," she adds.

The case managers are careful not to interfere with the patient-physician relationship, Fullerton says. Instead, they try to make people responsible for their own health care and to be proactive about taking care of themselves.

"Instead of being directed by a nurse or a physician, we encourage them to take ownership of their own health. Even though we give the information to the members, once they leave the doctor’s office, it’s up to them. The patients have to be their own advocates," she says.

The nurse case managers provide members with the education they may or may not receive when they go to the physician’s office.

The physician may tell a member he has congestive heart failure and explain it, but the member may not have a full understanding of the condition when he leaves the office. "Our goal is to educate the members about their conditions, how they should management them, and what tests they should have," Fullerton says.

Members with diabetes should know that they need a hemoglobin A1C test every three months and remind the physician if he or she doesn’t order it. "We are really trying to prompt our enrollees to be aware of the standards of care," Fullerton says.

The health plan considered leaving the educational aspect to the primary care physicians but decided instead to supplement whatever education the members receive at the physician office, Caison-Sorey says. "It’s not to say that the physicians don’t do what they should do, but they may talk in a way the patient doesn’t understand. They may think they have communicated with the member, but when the member leaves, he or she is confused," she adds.

The case management department came up with a patient-driven program.

"When we create plans of care and identify issues, it is with the member and not the hospital discharge planners. We work with the members to determine what they want to do with their health care," Fullerton says.

The disease management component also is member-driven. When they deal with members who have chronic illnesses, the case managers address the members’ issues as well as the issues they, as health care professionals, feel are important.

As an example, a case manager was working with a diabetic who mentioned that he had a sore on his foot. The case manager was gearing up to deal with the foot, but the member was more concerned about his diet. She addressed the diet issues with the member while educating him on the importance of foot exams and care.

"We can’t take what is important to the patient out of the picture," Fullerton says. If a member who is in the program is hospitalized, his or her midlevel disease management/case management nurse knows immediately, thanks to a new integrated computer system. In the past, the disease management case managers didn’t find out about inpatient hospitalizations until much later.

The case managers have access to information about the member through pharmacy records, claims data, and inpatient and outpatient utilization. When they study the data, the case managers are able to see how the members’ health care is being addressed.

One case manager identified a patient who was seeing 12 specialists with no listed primary care physician coordinating the care. "It’s very fruitful for the case managers to see the practice patterns. It helps us to discuss the conditions with the members and better coordinate their care," Fullerton says.