DM nurses, CMs provide seamless care

Patients transitioned from DM to CM and back

Disease management is a fluid process that often involves transitioning patients from the disease management team to case management for more intensive interventions, says Pam Mays, MPH, BSRN, RN, assistant vice president for care management of CIGNA Health Care.

CIGNA’s Well Aware disease management program coordinates patient care throughout the continuum, whether their case is being handled by the health plan’s in-house case managers or by the disease management nurses at American Healthways, the Nashville, TN, disease management vendor.

"We have a process to support the patient wherever they are, and regardless of the intensity of the intervention. When the patient is in case management, the disease management nurse is supporting the patient as well," Mays says.

If the patient has an exacerbation, or the Well Aware nurse is aware of a problem, she works closely with the CIGNA case manager to take care of the patient’s needs.

For instance, the disease management nurse may call a patient who mentions that he has a wound that isn’t healing.

The disease management nurse notifies the case manager, who assesses the patient and may bring in a home health nurse and notify the patient’s physician.

At the same time, the disease management nurse continues the ongoing education in support of the physician’s treatment plan.

When a member is hospitalized, the CIGNA case managers keep the disease management nurse aware of the patient’s condition. The disease management nurses go on to communicate by telephone with the clinical team and the case manager from CIGNA to share information.

"We call in the disease management nurse to discuss the case and participate with the clinical team. It supports consistency in care," Mays says.

Once the patient is stabilized, he or she is referred back to the disease management program. "It’s a streamlined process. The intervention through disease management is ongoing. If the patient needs more intense services, case management comes into play," Mays says.

Only a small subset of the 500,000 people in CIGNA’s disease management programs need the case management interface, she adds.