DM programs reap rewards for insurer and members

Nurses work closely with regional case managers

Centralizing all of its disease management programs has paid off for Aetna.

The insurer, based in Hartford, CT, won the Best Disease Management Program in Managed Care award from the Disease Management Association of America (DMAA).

The company was cited for its Healthy Outlook Program Caring for Congestive Heart Failure, which it conducts nationally in conjunction with LifeMasters Supported Self Care, an Irvine, CA-based disease management company.

Aetna’s congestive heart failure (CHF) program received the DMAA award for demonstrating organizational commitment to disease management, employing science in the design and implementation of the program, and for the favorable outcomes that have been measured using a carefully designed methodology.

Until 1998, Aetna had a variety of disease management programs with regional variations.

"We consolidated our programs in 1998 to take advantage of best-in-class practices, standardize our approach across the regions, and make our programs industrial strength. Because we support patients all over the United States, we’ve designed our programs carefully to achieve consistent quality results that demonstrate real value to our customers from Texas to New York," reports Michael Reardon, MD, national medical director and head of Aetna’s Member Advantage Programs.

The company set priorities for its program improvements starting with diabetes and CHF because they are high-cost diseases that affect members’ quality of life and because the company has a large population with both diseases. For instance, nationwide, Aetna has about 30,000 members with CHF.

"We started with those two programs because we wanted to get them to the market first and then built our own internal capabilities using the same philosophy and approach," says Rose Kaufman, project manager, vendor relations and program strategy.

Aetna chose to use LifeMasters Supportive Self Care, an Irvine, CA-based disease management company, for the CHF and diabetes programs and has developed internal programs for other diseases.

"A cornerstone of the programs’ success has been our commitment to a continuous quality improvement approach to disease management. Quite simply, we work every day to make our programs better," Reardon says.

The programs have paid off, he adds.

For instance, members who have participated for at least six months in the CHF program showed significantly improved compliance with an appropriate treatment regimen, fewer emergency department admissions, and shorter hospital stays.

Since the programs began, Aetna’s asthma population has experienced a decline in the utilization of hospital services and emergency department visits. Patients with diabetes and coronary artery disease have shown a decline in hospitalization.

"We’re seeing an improvement in clinical outcomes and quality of life for members in all our programs," Reardon says.

Rigorous member identification and stratification is another cornerstone of Aetna’s disease management program, according to Reardon. "We have gotten very sophisticated with our predictive modeling algorithm that helps us identify patients who need the most help," he says.

Aetna Integrated Informatics, the company’s health data division, maintains a huge information warehouse containing 14 terabytes of data that the company uses for the risk stratification and predictive modeling for its disease management programs.

Collaboration between the disease management nurses and the company’s regional nurse case managers is a key element of the insurer’s disease management efforts.

While Aetna’s disease management is centralized, the case managers operate in the company’s regions throughout the United States.

"Because we have a centralized utilization management system where all the data about all our members are collected, the internal staff are able to see what is happening with the member on a day-to-day basis. For instance, if the member with diabetes is in the hospital, the concurrent review nurses send the referral to disease management," Kaufman says.

There is a two-way flow of information between the disease management nurse and the case management nurse. For instance, if someone has home care needs, the disease management nurse and the case manager work together.

"They are all on the same platform and can see other each other’s cases. It’s not unusual for the disease management nurse case manager to confer with the case manager," says Meg Dee, RN, manager, Informed Health Line and Disease Management Programs.

The team takes advantage of the "teachable moments" that typically occur when a member has just gotten home from the hospital.

As the case manager works to set up home care services, she confers with the disease management nurse to let her know when the patient is stable enough to be ready for more education.

"When we designed the program, we spent a lot of time creating workflow systems to ensure that there would be a seamless transfer of information between our nurse case managers and the LifeMasters disease management nurses," Kaufman says.

For instance, the disease management nurses in the company’s low back pain program focus on preventing re-injury and teaching members first-aid treatment for low back pain.

The nurses in the company’s diabetes disease management program focus on helping patients understand and comply with their physician-prescribed treatment plan.

As members are identified for Aetna’s disease management programs, they receive a mailing with information on their specific conditions and a telephone number they can call if they have any questions. Patients who are identified as moderately at risk or at high risk in the CHF, diabetes, coronary artery disease, and asthma programs receive aggressive outreach. A disease management nurse calls them to talk about treatment options and provides information to help them make informed decisions.