Nurses help members navigate system

Callers get information on conditions, benefits

HealthPartners of Minneapolis has created a program that bridges the gap between the health plan’s member services line and the after-hours nurse triage line.

The Nurse Navigator program, launched in August 2000, is staffed by nurses who answer questions about medical conditions, clarify benefits related to medical conditions, facilitate the benefits in complex cases, help members find credible medical information on the Internet, and link members with appropriate providers and services.

When Scott Aebischer, the plan’s vice president of customer and member services, began working with the plan’s call center, he noticed that a lot of members were calling in for help in learning how to get treatment for complex medical needs or chronic conditions, and operators at the health plan’s member services line were not equipped to handle the calls.

"A lot of these callers to member services had just been diagnosed with a condition. They wanted to know who they should see, how do they set it up, and how it relates to their benefits," Aebischer says.

The member services operators could easily handle calls that involve claims inquiry, benefit information, change of addresses, new identification cards, and other topics.

Managing logistics of care

"Member services representatives don’t know about medical care and treatment. They don’t know about conditions or pharmacy or the medical industry. They know about benefits and how to help people find out about their health plan," Aebischer says.

HealthPartners created the Nurse Navigator program in August 2000 as a way to supplement its other telephone services to members.

This was an area where the level of frustration of the members was easily resolved," he adds.

The program is staffed by five nurses who deal with commercial members and three who handle the government-related insurance business.

The nurses are housed within the member services’ sections.

When a member calls in to member services during regular office hours with needs the Nurse Navigators can handle, the representative puts them on hold and alerts the Nurse Navigator.

The Nurse Navigators have been training to talk with members about their benefits and their medical conditions as well.

For instance, if a member has been prescribed a new drug, the Nurse Navigators can help them understand what it is and how to take it.

"They manage the logistics of care," Aebischer adds.

The Nurse Navigators have access to the health plan’s benefits on-line and can work with each individual to maximize them.

For example, if the benefits don’t allow the option the member wants to pursue, the nurses help him or her find someplace that does work.

"We are changing the process. Rather than working with the benefits after the fact, we are helping them make the choices in advance," he says.

Suggesting options

For instance, if a member wants to go to the Mayo Clinic and the benefits don’t cover it, the Nurse Navigators might help him or her find a physician who trained at Mayo.

If a member calls in and has been prescribed a drug that isn’t in the HealthPartners formulary, the Nurse Navigator may tell the member about other, similar drugs that are covered and suggest that they discuss it with their physician. In some cases, the Nurse Navigator may call the provider to see if he or she will prescribe the similar drug that is covered.

"The nurses help the consumers with their role in discussing the situation with their provider," Aebischer says.

Nurses who answer the health plan’s Careline, an after-hours nurse triage service, also refers people with complex needs to the Nurse Navigators.

For example, a member may call the Careline to find out about gastric bypass surgery and be referred to the Nurse Navigators for information about whether his or her benefits cover gastric bypass surgery and what criteria he or she may meet.

Nurse Navigators who are specialists in geriatric care help Medicare beneficiaries get through the Medicare maze, explaining what the terms mean and making sure they get to the right physicians.

They help people find community programs that will help them. If they need durable medical equipment, the Nurse Navigators explain what it means and help them find something that will meet their needs.

"Providers are doing everything they can, but often members are listening only to part of what a caregiver says. When they get home, they have a lot of questions. In the past, they’d call their doctor; but these days, the clinics are so busy they may not be able to get an answer quickly," Aebischer says.

In 2001, the nurse line received 13,861 calls and made 37,974 outbound calls. By 2002, the number had increased to 22,768 inbound calls and 42,916 outbound calls.

"The response has been enormously positive, as shown by the steady increase in call volume as well as from individual success stories by members," he says.