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A review of its 1995 claims data revealed that six of Blue Care Network of Southeast Michigan in Southfield primary care groups had exceptionally high utilization among its pediatric asthma patients. The HMO immediately pulled together representatives from every facet of the organization to develop an asthma management program that successfully reduced annual utilization costs an average of $673 per program participant. (For other program results, see box, below right.)
"Our approach was to go after those high utilizers of service, the patients with obvious treatment failures. Asthma is a disease that responds well to treatment. Good management can make a difference in medical costs and quality of life," says James J. Lewandowski, RN, MHSA, manager of health promotion and disease management for the HMO.
Blue Care Network called in representatives from all departments to work on the program. "You really need all departments to get a disease management program up and running," says Lewandowski. "Our provider representatives and the relationships with our providers get our message out. Our quality management department had the necessary expertise in the continuous quality improvement method to help us look at outcomes management."
Blue Care Network first launched the Asthmatter of Fact program in those six primary care groups with the high utilization rate for pediatric asthma. "We sent postcards describing the program to the families of children who had experienced treatment failures," he says. "This was a targeted, personalized communication that said the health plan was aware the child might be having an asthma-related condition and inviting them to participate."
Many of the families didn’t understand what the health plan was offering and didn’t express an interest in enrolling in the program, Lewandowski notes. "Each time the child was admitted to the hospital or emergency room, we sent another letter to the family," he says. In addition, a Blue Care Network nurse called the family to offer information about the Asthmatter of Fact program soon after the child’s inpatient admission or emergency room visit. "We know that in terms of changing patient behavior our best chances come during the event and immediately after the event. If we approach them several weeks or months after an asthma episode, they have no interest in a management program."
On the provider side, Blue Care Network developed a comprehensive patient profile for each child in the high utilization group. The profile lists what medications the child was taking, and how often the prescriptions had been filled in the past 12 months, as well as any admissions. "This is the first time these physicians had seen this type of administrative report for their patients," says Lewandowski. "We made it clear in a letter that accompanies the reports that we would like them to recommend their patients participate in the program."
Physicians were reluctant to accept the information contained in the profiles, he says. "They wanted to know where our information was coming from. It’s simple, 90% of our members have pharmacy coverage, so we can track their prescription history." In fact, one physician called him to inform him that the profile of his patient was wrong. "He said I prescribed this drug for my patient that doesn’t appear on the patient’s profile. I suggested he call the family and check to see if the prescription had been filled. He later called me back and told me the family hadn’t filled the prescription because the child improved." Physicians now receive patient profiles on a quarterly basis.
In addition to trying to change member behavior, Blue Care Network was also interested in changing physician behavior. "In reviewing these profiles, I often didn’t see the numbers of refills or types of prescriptions I would have expected," says Lewandowski.
Once a physician approves a patient’s participation in the program, Blue Care Network sends the referral to a local home care agency, he says. "We surveyed local providers and found those that met our specifications for what we considered asthma expertise. We worked with them to develop two asthma manuals — one for patients and one for providers."
Blue Care Network also had a nurse clinician train physician office staff how to deliver asthma education to their patients. "It’s more often the office staff that educates the patient, not the physician. We felt including the staff in asthma education was an important step. Luckily, we received an educational grant from a pharmaceutical company to cover the costs of staff education," he explains.
A home care nurse goes to the patient’s home to deliver the eight teaching modules in the patient manual. (For a list of modules covered in both manuals, see box, above.) The home care nurse makes an average of four visits to cover the information in the manual. "We average between two to up to eight visits for a family that is really having trouble," says Lewandowski. "The learning visits take place over no more than a four week period, and ideally are completed in two weeks."
In addition to asthma education, the home care nurse provides the following services:
• evaluates the home for environmental asthma triggers and discusses them with the family;
• observes the children using their inhalers and peak flow meters;
• helps the physician develop a personal asthma kit or management plan for each child and then goes over that plan with the family;
• coordinates visits with an allergist.
Patients enrolled in the Asthmatter of Fact program receive quarterly phone calls from the home care nurse. "The nurse goes over compliance issues, asks how the child’s peak flows have been," says Lewandowski. "The nurse also checks for potential signs of trouble our claims data might not pick up, such as missed days from school due to asthma."