Coaches work with diabetics, at-risk members

Nurses follow patients across the continuum

In addition to providing health coaching and care coordination for members who already have developed diabetes, Independence Blue Cross, with headquarters in Philadelphia, provides coaching for members at high risk for developing the disease.

The health plan recently combined its disease management and complex case management programs and trained nurses in both programs to become primary health coaches and work with patients across the continuum of care, says Diana Lehman, RN, BSN, director of care management for the health plan.

In the past, if members were receiving disease management for a condition and developed comorbidities or were hospitalized, in many cases a complex case manager would coordinate care until they were stable, then transfer care back to the disease manager.

“Now one nurse follows individuals whatever their needs. Members build a trusting relationship with their nurses, which improves communication and ultimately results in better patient care,” she says.

Each month, the health plan analyzes claims data and information from the members’ health risk assessments, then stratifies members based on their risk factors. Members at moderate risk receive an automated telephone call informing them of risk factors and recommended tests, and also receive a packet of information in the mail. Members with low risk for developing the disease or whose diabetes is better controlled receive a mailing containing information about preventing diabetes.

Members stratified as high risk receive a telephone call from an RN health coach who engages them in the coaching program. This includes members with risk factors for cardiometabolic syndrome, which can lead to diabetes and heart disease as well as those who have the disease but are not managing it well. Risk factors for cardiometabolic syndrome include obesity, elevated cholesterol and triglycerides, hypertension, and elevated fasting glucose levels. Members who have been diagnosed for diabetes are identified for coaching if they have gaps in care, if they make frequent emergency department visits, if their blood sugar levels are not under control, or if they are not filling their prescriptions.

“When they call members, the nurse health coaches can access both the claims data and the members’ health risk assessment via a 360-degree view of member activity and tailor the conversation around the members’ needs,” Lehman says. For instance, they may discuss tests the member has missed or ask why the member hasn’t filled prescriptions for medication.

The nurses ask a series of questions and use all the information to work with the member and develop a care plan. The nurse identifies issues and barriers to care and finds out what the member wants to tackle first. “If someone is a smoker and says he doesn’t want to quit, that’s not something to work on. By identifying what is important to the members, the nurses build trust, which enables them to work on other issues in the future,” she says.

The health coaches have received extensive training on coaching and motivational interviewing and how to help members change their behavior.

“Nurses have a tendency to want to fix people and tell them what to do. Instead, our coaches listen to where they are and use the skills they have learned to help members come to their own conclusions about making behavioral changes,” Lehman says.

Members typically have a plan of care from their doctor but they need help understanding it and knowing how to follow it, Lehman points out. “For instance, they may be told to eat a healthy diet but they lack the knowledge to determine what they should and shouldn’t eat. The nurses help them understand what they should do. If the physician recommends exercise, the nurse helps the member set goals and build their exercise plan,” she says.

The nurses determine members’ knowledge deficits and educate them on the missing parts. With diabetics, they teach them the importance of checking their blood sugar throughout the day and complying with their medication regimen. They help members identify community resources, such as diabetes classes at local hospitals.

The nurses follow up with the members and go over their plan of care at intervals determined by the individuals’ needs. They contact the members’ physicians if appropriate or have the health plan’s medical director contact them. If they have questions about medication, they can talk with a health plan pharmacist. “We have integrated all the components of care to maximize benefits to the members,” she says.