Calls remind members of gaps in their care

Program integrates with CM, DM

To help members of its Medicare Advantage Plan stay healthy, healthcare professionals at WellPoint make individual outbound calls to members with clinical gaps in care to remind them of what preventive measures they need.

In a pilot study, the members who received the calls reduced their care gaps from 15 to 5.9 percentage points for each of nine measures. The program won a URAC gold award for consumer health improvement.

"We wanted to change the way we approach the members. Unlike population based initiatives, this program is member-centric, driven by member needs and care gaps," says Catherine MacLean, MD, staff vice president of clinical quality and intervention for the Indianapolis-based health benefits company, which operates commercial, Medicare, and Medicaid plans in many states. Traditionally, health plans have provided case management for the sickest members and conducted population-based campaigns to remind members to get their flu shots and have regular screenings, she points out.

"We are not just sending out random calls. We are determining everything needed by the member and tying that into the calls. This isn't an Interactive Voice Response (IVR) call. The members get a call from a live person," she says.

WellPoint analyzes medical claims data every month to identify clinical gaps in care according to evidence-based clinical practice guidelines. Members with one or more gaps receive outbound calls from patient education coordinators who educate them about the gaps, encourage them to seek whatever tests or procedures are missing and offer assistance in scheduling appointments.

"Seniors have health problems that are different from those of other age groups. They have risks for falls, urinary incontinence, and other issues that are unique to older patients. This program aims to address those problems and help our members optimize their health," McLean says.

The patient educators are college-educated but do not necessarily have clinical degrees. The company provides extensive training to help them do their job.

The patient education coordinators talk with the members about all of their healthcare issues, not just the preventive measures they are missing. If members have a question about medication, the patient education coordinators can transfer them to a pharmacist. If they have clinical issues, they are transferred to a case manager or a disease manager. They help them with doctor appointments and transfer them to a social worker for help if they have additional needs, such as transportation, financial needs, or community resources. Depending on the provider group, the patient education coordinators will arrange a three-way call with the doctor's office to set up an appointment or contact the provider group staff to call the member to set up an appointment.

"This is a more holistic and meaningful approach. We put this all together so we aren't operating in silos. The patient education coordinators can connect members to whatever Wellpoint program can meet their needs," McLean says.

The program is integrated with another WellPoint program that calls members just before discharge and after they get home to make sure that the transition is going smoothly, that they have a follow up appointment with their physician, and that they understand their medication.

"Problems that arise when patients transition from one level of care to another are big issues for every age group, so we make the calls to all our members, regardless of age. However, ensuring a smooth transition is particularly important for the senior population," she says.

The program is year-round. Every month, the health plan analyzes data to identify members with care gaps. Members are called back repeatedly when data show the care gaps haven't been closed. Some members may receive as many as six calls a year.

Members who are new to WellPoint's affiliated Medicare Advantage plans complete a health risk assessment that is used to identify potential gaps in care. The health benefits company uses medical and pharmacy claims and other data to identify members for outreach.

The goal is to contact each member at least twice a year. Patients newly diagnosed with diabetes, heart failure, or coronary artery disease and those who have persistent clinical care gaps get three calls a year. The health plan records the calls and conducts monthly auditing and quality review to make sure the patient education coordinators are meeting appropriate standards.

"We developed this program for seniors because they are more likely to struggle with poor care coordination, health literacy, access to providers, transportation issues and other barriers to care that reduce adherence. The program allows members to be proactively involved in their own care by notifying them of preventative screenings that can detect and prevent chronic illness and educating them on the potential benefits of getting the recommended tests and procedures," MacLean says.