Personal Nurses take a proactive approach

Revamped program strives to empower members 

At Humana Inc., specially trained registered nurses called Personal Nurses fill the gap between the company’s traditional case management and disease management programs.

The nurses, who work from home-based offices, call members identified by a predictive model as likely to need health care interventions in the future, says Trish Whitt, RN, director of clinical product management for the Louisville, KY-based health benefits company.

About 85 nurses have been trained as Personal Nurses. Humana’s goal is to have 150 Personal Nurses in place by the end of the year.

A predictive modeling tool developed by Humana’s Center for Health Metrics uses medical and pharmacy claims data and demographic data to tell the nurses which members are going to be the sickest over the next year. They include people who have had a lot of care, those with significant new diagnoses, and those with events in the past that indicate they’re likely to need health care interventions in the future.

Rather than calling them after they are hospitalized, the nurses reach out before a crisis occurs.

"A lot of them have had a major health event. We intervene before it gets worse," Whitt says.

The program provides services for members who don’t fit into traditional case management or disease management models, points out Vaughn Keller, MFT, EdD, Humana’s director of clinical behavior changes, who provides the training for the company’s care management staff.

Most people who are referred to case management have multiple problems and need coordination of services on a short-term basis. Disease management programs deal with chronically ill members.

The first version of the Personal Nurse service was rolled out in 2001 at the market level with nurses in all of Humana’s market offices calling members, finding out their needs, and working with the providers to coordinate care. Humana covers members in 19 states and Puerto Rico and has regional offices in areas where they have the most significant populations.

The Personal Nurses worked in the regional offices in traditional cubicles and called patients within 48 hours of discharge from the hospital.

"We took more of a reactive approach rather than reaching out beforehand. It was more of a case management program with a focus on arranging medical care for the member rather than empowering the member to manage their own health needs," Whitt says.

Program modified

Over time, a review of the program found that the nurses were spending a lot of time on provider issues, such as calling hospitals or medical providers to coordinate discharge services and obtaining information from providers about a member’s discharge plans.

"We wanted the nurses to focus on empowering the members to set positive health goals and identifying strategies for improving their overall health," Whitt says.

The program was modified in early 2003.

Now, instead of working in the market office, the nurses are home-based, with flexible hours that allow them to interact with the working members in the evening and on weekends.

"They were trained heavily on specialized communication skills, motivational interviewing, and modification of health behavior," Whitt says.

The nurses work at home with personal computers. When they are ready to take on a new member, Humana’s web-based application, which was developed internally, brings up the next sickest member in the order of predicted severity, along with the demographic information, severity score, and information needed to contact the member.

When they contact the members, the nurses assess members’ knowledge of their condition and readiness to change level. They assist members in developing a personalized strategy to manage their health care needs.

"If a member is at a level where they have not dealt with the disease process at all, the first step is to find out how much they know about their condition and facilitate the education process," Whitt says.

The motivational interviewing techniques that the nurses use when interacting with the members help increase the members’ conviction and confidence level in making changes to their lifestyles.

Under the new model, a medical management department that is entirely separate from the Personal Nurses handles utilization management and coordination of care activities with the hospital and other providers to make sure the members get the services they need after discharge.

"This allows the Personal Nurses to spend their time working with the members and focusing on behavioral changes. It’s part of our move to be more consumer-focused," Whitt says.

Members who have specific conditions and need intensive services to help them manage their diseases are referred to a disease management program. Personal Nurses made more than 1,000 referrals to disease management programs last year.

"We want the members to feel empowered in managing their health care and be able to make their own decisions through collaboration with their health care provider," Whitt says.

The nurses are assigned cases by geographic location. "Because of various Nursing Practice Act regulations, we require the nurses to be actively licensed in all states in which their assigned members reside and receive health services," she says.

The Personal Nurses focus on members the predictive model shows are at the greatest risk for adverse health events. Humana does not solicit calls from members until the predictive modeling tool has identified them.

Most of the personal nurses say they enjoy working from home, although some found the isolation of a home-based office to be a difficult transition, Whitt says.

Part of their training program teaches the nurses how to handle the transition to working at home, including how to set up an office, how to make sure members of the household recognize the importance of their work, privacy requirements, and dealing with the isolation after working in settings where there is a lot of social interaction.

Nurses in the Personal Nurse program have told Whitt that they enjoy being able to interact with members rather than arranging and coordinating medical services with a hospital or another provider.

"Productivity has been very good with the home-based model and is consistently improving as we learn new ways to leverage technology for our nurses," Whitt says.

The nurses keep in touch through an instant messaging system that allows them to get an immediate response from a Personal Nurse Coach or another Personal Nurse. They have access to an electronic bulletin board with frequently asked questions and answers posted and receive a weekly newsletter with updates and reminders on operational issues.

After the nurses are in the field, they are monitored by a coach, an experienced personal nurse who has a caseload of his or her own but who is responsible for monitoring the work of 10 other nurses.

"Coaching is an absolutely essential part of this work," Keller says.

The coaches provide feedback and suggestions to the individual nurses and work with the company to identify areas where the program needs to be tweaked.

"We look at areas where it appears to be consistent across the entire group that we need to do additional work, and that becomes our focus," he says.

In addition to their experience, the Personal Nurse coaches have proven to be extremely effective and have the ability to coach other people, Keller adds.

"They still work with their own panel of patients. We don’t want them to become too distant from the patients," he says.

The coaches can send a real-time message to the nurses while they are on-line with the member and suggest other avenues they can explore. As soon as the nurse finishes her call, the coach will call to discuss it.

Each coach works with 10 nurses and has at least one coaching session a week with each one.

They pick up calls at random and can audiotape them so they aren’t just working from memory when they discuss the information with the nurse.

"The nurse may be so focused on the call that she forgets what is said or misses something and the coach can replay it right away. This is similar to the process used to train psychotherapists when they are observed from behind a one-way mirror," Keller says.

Over time, Humana will be able to look at claims data and determine whether the Personal Nurse intervention has reduced expenditures, he explains.

In the meantime, the health plan has determined that the members who have worked with the nurses spend fewer days in the hospital and make fewer visits to the emergency department than people in the control group, members with the same types of conditions and risk factors who are not part of the program.

"We also know that they spend more money in certain areas, such as pharmacy, because they’re adhering more to the drug regime, and more money on outpatient visits because they are following through on the care plans that keep them out of the hospital and emergency room," he says.