In-house program gives support at stressful time

CMs work with breast, lung cancer patients 

As part of its mission to provide peace of mind to members, Premera Blue Cross has developed an innovative case management program to help members with breast and lung cancer understand their disease and make informed choices about their treatment options.

The company initially worked with a vendor to develop and provide comprehensive disease management services for members with breast and lung cancer, then transitioned the services in-house.

The Mountlake Terrace, WA, health plan has five nurse case managers with oncology experience and additional training who are dedicated to the program. They carry a caseload of 35-45 members at a time, working closely with members to educate them about their condition and treatment options and to help them avoid complications during treatment.

The case managers follow the members who are in active treatment and who have end-of-life needs. After a case is closed, they follow up every three months to see how the members are doing and determine whether they need to be called more frequently.

The cancer management program is a combination of traditional disease management and case management, points out Golda Posey, RN, MS, manager for the Premera’s disease management program.

"We are providing interventions from traditional case management combined with population health or disease management. We want to make contact with the member early on in active treatment and continue follow up to make sure that we are able to offer support and education for condition changes that may occur months after active treatment has been completed," she says.

Breast cancer and lung cancer were near the top of the list when Premera studied the most troubling diagnoses for members in 1998 and contracted with the vendor, says Liz Grunte, RN, disease management program administrator.

Originally, the vendor provided a broader population-based program for cancer patients. Later, Premera decided to concentrate on providing individual case management targeted only to the members who would benefit most from the program.

"One of the things we learned in our experiences with the vendor was that simply monitoring the patients or having them be part of the program when they didn’t really have any needs didn’t provide the kind of value that our one-on-one case management can provide. We built on what we learned while we worked with the vendor and, integrating a dedicated team of Premera disease-focused case managers, brought the program in-house," Grunte says.

The program is offered to Premera members with a primary diagnosis of breast cancer or lung cancer whose employers have purchased the service. Patients are identified by referrals from health plan staff, providers, and an examination of claims data.

When the case managers receive a referral, they research the Premera claims to find out the stage of cancer, what treatments the patients have had or are undergoing, and where the patients are in the course of treatment, says Catherine Kinnunen, RN, oncology case manager.

Then they call the member and do an assessment to find out their needs. "We are getting in touch with members at a time when they feel they have the least control over their lives. The purpose of the program is to empower the member to get optimum outcomes from the care they receive," says Mary Murray, CCM, RN, CPQ, manager of case management.

The case managers educate the members about national cancer treatment guidelines and answer any questions the members may have.

"Oncology nurses love to teach. We provide a lot of information and support. We provide education verbally on the telephone and supplement it with written information and refer them to approved Internet sites. We have a lot of members who are computer literate but don’t want to surf for information about their disease. We give them places they can look," Kinnunen says.

Premera’s oncology advisory physician group reviews the materials and Internet sites.

"A key piece of the program is providing resources. It’s a time when people are overwhelmed and need someone to guide them to the information they want to know from sources that are reliable," Grunte says.

Helping to ask questions

The number and intensity of interventions depends on the stage in the disease process, Murray adds.

"We get some referrals right after the patient has gotten the positive biopsy and others after they are in the latter stages," she says.

Those who have just received the diagnosis or those who are in the final stages of the disease may need a lot of help. Patients who are completing their treatment may not need a lot of interventions.

The case managers work with the physicians who created the treatment plan for the patients, often helping the members come up with the right questions to ask their physician and helping them phrase the questions correctly.

"When people are in a crisis in their lives, they may not know which questions to ask their doctor and how to ask them. We’re there to help them with the questions," she says.

If a member is referred at the beginning of the treatment, the case managers tell them what to expect from the first visit with the oncologist and what to expect from their treatment.

The case managers typically call patients who are recently diagnosed and just starting their treatment twice a month or more, depending on their needs, then taper off to once-a-month calls, Kinnunen says.

"Being diagnosed with cancer puts people in an emotional tailspin. We have all had patients call us when they are very depressed. We work closely with them and their family members if we have permission to speak to them, and refer the members to our behavioral health case managers if they need more support than we can give," she adds.

Members are encouraged to call the case managers with any questions or concerns they have. Some members call the case managers frequently. Others, who continue to work during their course of treatment, often don’t have time to call.

"We make sure we do the outreach to these members and make sure everything is OK. How long we follow them depends on the patient. I’m still following some patients nine months after the program began, but there are a lot of cases that have been closed," Kinnunen says.

The case managers and the patients make a joint decision on when the case is closed. "As long as both feel there is value in the contact, we will continue to call them. They know that they can be discharged and still have the ability to call us back if they need us," Grunte says.

"Calling the member is the most important part of the service. It gives them help with managing their lives at a difficult time," Posey says.

When members are approaching the end of life, the case managers do whatever they can to ensure that the patients are comfortable, starting with assessing when the member needs hospice care.

"It can be difficult because sometimes patients and family members are in denial. People have a misconception about hospice care. They think that if you’re there, you’re going to die shortly. Our goal in supporting the physicians’ and members’ decision to involve hospice is to make the members as comfortable as possible and to provide assistance with end-of-life issues," she says.

The case managers educate members and their families on the kinds of services that hospice offers and when the services are appropriate and on eliminating misconceptions, such as the idea that those patients who are receiving chemotherapy or radiation for palliative purposes can’t receive hospice care.

Having case managers work with cancer patients saves money because the members have appropriate information for making health care choices and because the case managers often can help the members prevent complications, Posey says.

For instance, when members receive chemotherapy treatments, their immune system is suppressed and they are more likely to get an infection if exposed to outside forces. "Whenever a patient with a suppressed immune system goes into the hospital because of an infection, their stay can be quite lengthy," Kinnunen says.

The case managers work closely with the members providing verbal and written education on how to avoid infection. "Most people know to avoid crowds, but we caution our members who are farmers to make sure they stay away from the barns and to make sure their family members wash and change clothes before coming in touch with them. Animals are a big source of infection," she says.

With another member, a teacher, the case managers cautioned her to stay behind her desk and not walk up and down the aisles to be exposed to coughing and sneezing students. "We teach them to avoid crowds, to wear a mask if they have to go out, and to practice good hand-washing precautions," Kinnunen says.

The case managers emphasize that their role is to support the physicians and their treatment plans.

"The only time we might interfere at all is if a member wants to investigate a really alternative source of treatment. In that case, we would caution the member and, if necessary, make contact with the member’s physician to make sure he or she is aware of what the member is considering. We want the member to be safe as well as informed about alternatives," she says.

"The case managers are in a position to identify side effects and complications that the provider may not know about. In that case, they make sure the provider knows and can adjust the medicine or otherwise help the member handle the complication," Kinnunen says.