Integrated DM program supports recommendations

Highmark Blue Cross Blue Shield combined its previously disjointed disease management programs into an integrated condition management program that focuses on reducing the variations in effective care for five common conditions.

The health plan uses its "health coaches" for condition management, shared decision making, and for general health information and support.

The health coaches are registered nurses, dietitians, and physical therapists. They give patients information about their condition and help them make good health care decisions.

Patients who are eligible for the integrated condition management are identified through claims data, including pharmacy and standard medical-surgical claims. They are stratified based on the plan’s prediction of utilization and cost.

The outreach is targeted to the severity level. Some patients get a mailing on their condition. Other may get active health coaching on a one-to-one basis from a case manager who is a nurse, a diabetic educator, or a therapist.

Most of the health coaches are registered nurses with a lot of experience and the ability to provide information that is customized to the needs of the patients, says Don Fischer, MD, MBA, a medical director for the Pittsburgh-based insurer.

"The health coaches help them understand why the physician has prescribed a certain regime and give them reinforcement and information so they can comply," Fischer says.

The health coaches also help educate patients who may be trying to decide among treatment options. "If you give patients unbiased information about the pros and cons of choices with equally valid scientific evidence, they will typically choose the most conservative option and be happier and more compliant," Fischer says.