High-risk members are focus of DM program

Members are identified by data, other factors

Aetna’s award-winning disease management programs focus the company’s resources and nursing skills on the patients for whom it can make the biggest difference.

"We are always looking at other ways to identify members who are at risk so we can initiate interventions to impact the quality of their lives," says Michael Reardon, MD, national medical director and head of Aetna’s Member Advantage Programs.

The company uses the information in the Aetna Integrated Informatics division’s data warehouse to identify members who are at risk for disease and to stratify them as to their risk level.

All members who are identified for the disease management programs are sent an outreach letter encouraging them to call Aetna’s disease management line if they have any questions or concerns.

The company focuses its telephonic disease management support on members who are stratified as high risk and others who were not stratified as high risk by the data but other reasons may indicate that they are at risk for an acute episode of their disease.

"The claims and predictive modeling methodology is excellent, but it’s not perfect. For example, new members may not have claims experience in our system in the early part of the year. That’s why we look for other ways to identify members who are at risk," Reardon says.

For instance, a member with asthma who was stratified at low risk may call the company’s disease management line with a question about a recent asthma attack.

"When someone calls into our disease management line, we do a full health risk screening to identify things in their history that might mean the member is at higher risk," reports Reardon.

Or, a member with asthma may call the disease management line and indicate he or she wants to quit smoking.

If the information from the health risk assessment or the telephone call indicates that a patient would benefit from more outreach and a high-touch program, he or she is switched to a targeted level, Reardon adds.

The disease management nurses call targeted members. "Once we reach them on the phone, the program is tailored to whatever the member needs," says Meg Dee, RN, manager, Informed Health Line and disease management programs.

All members in disease management are screened for depression. If they screen positively, the disease management nurses work with the company’s behavioral health specialists to get the members into an appropriate treatment program.

The nurses in the disease management program use an assessment tool to identify symptoms, medical issues, and learning deficits the members may have. They use the Prochaska Readiness to Change model to determine how ready the members are to lose weight, start exercise, stop smoking, or change their diet.

"We work on setting mutually agreeable goals with the member and determine the next time the disease management nurse should call them again. We work hard to get buy-in from the member," Dee says.

The disease management nurses focus first on the most critical factors that are identified through the screening process. They emphasize the importance of taking medication regularly, understanding the treatment plan, and being aware of the tests they should have and the results they should get.

"The nurses use their skills and tools to help the member make changes to reduce their health risk. We often hear from members how much the nurses do for them," Dee says.

The disease management nurses provide whatever counseling and support the members need on an ongoing basis.

"Our aim is to improve the quality of life for our members with chronic diseases," Reardon adds.

As the members meet their goals, the nurses will contact them less frequently.

Aetna sends all members a disease-specific newsletter twice a year and includes a telephone number they can call with questions.

The company’s programs take a member-centric approach to disease management.

"We want the members to know their disease, to know the numbers that are meaningful for their disease, such as their cholesterol or hemoglobin A1C numbers. We make sure they understand their treatment plan prescribed by their physician and know how to take their medication appropriately," Reardon says.