Health Advisor program helps members navigate fragmented health care system

Nurses serve as advocates and benefits experts

As employers contract with multiple vendors to get "best-in-class" health care services, an employee may have a medical plan managed by a managed care organization, disease management programs handled by a number of specialty vendors, and a pharmacy plan managed by another company.

That’s one of the reasons why CIGNA HealthCare began its Health Advisor Program in January as a way to assist employees and their families in navigating the health care system.

"Employers often choose multiple health care delivery partnerships as they try to get the best services for their employees. The employees may have access to a number of different programs, but they need someone to pull it all together for them," reports Rosemary Hummel, RN, assistant vice president of medical management program development for CIGNA HealthCare.

The program was developed in response to employers who were looking for a higher level of service for the employees and their families, Hummel says.

"The Health Advisors program provides a one-stop shop where members can talk to someone who is their advocate to help them get the right level of care in the right setting. They provide an answer to the confusion that those multiple entities might cause the member. The health advisors provide a holistic view of the member’s situation and make sure that all the member’s health needs are addressed, even if CIGNA doesn’t provide the services the member needs," Hummel says.

Health advisors try to optimize the overall member experience through added personal interaction and support, Hummel adds.

"This added touch is particularly important for individuals who may be experiencing catastrophic health events or for those with chronic conditions," she says.

Health advisors are nurses dedicated to a specific employee group, who are available by telephone or secure e-mail and act as health care coaches for their assigned members. They have access to the employer’s medical, pharmacy, and behavioral benefits plan as well as other programs offered by the employer that may or may not be administered by CIGNA.

"The service is akin to what patients receive in the hospital setting where there is a primary nurse who develops the care plan and provides oversight to make sure the patients are connected to the services they need. The Health Advisor nurse provides a similar service in an insurance setting," she says.

The nurse advisors provide members with direct access to counseling and education to help people who don’t fall within traditional care management programs. They promote prevention and self-care and coach members to better help and assist them in navigating through the complicated health care system.

The individual employees can pick up the telephone, call their assigned advisor directly, and ask questions about their condition, their treatment plan, or anything else related to their health care needs, Hummel says.

Although it’s too early for any definitive outcomes data, members, employers, and nurses who work in the program have had a positive response, she notes.

Members have expressed their satisfaction in knowing they can have someone who understands their situation and can help get the care they need, she adds. Nurses who have taken on the role of health advisor have reported being very satisfied with the change.

"They find the job very rewarding and have said they feel like they are making a difference in the member’s lives, just like they did when they were in the clinical setting," Hummel says. "It’s a win-win-win situation. The member, the employer, and the nurse all win when we utilize our expertise to maximize care."

Improved compliance

The program adds value by helping members gain access earlier to appropriate clinical programs and improves compliance with treatment guidelines by giving participants a single source for help, Hummel adds.

"If people are engaged early with the right information, they can make better choices early and help prevent more costly problems later on," she says.

When a company signs up for the program, the members are sent enrollment materials, including a program description and an enrollment card with information on how to contact their health advisor. When the members call, they are assigned a dedicated nurse advisor who works exclusively with them through that particular episode of care.

Members are identified for the program through self-referral, referrals from providers, and standard medical triggers and predictive scoring to indicate at-risk members.

For instance, the pharmacy data may show that a member has just received a prescription for a diabetes medicine. In that case, the health advisor may send the member educational materials, then make an outreach call.

Depending on the severity of the member’s condition, the health advisor may make a referral to a disease management program or refer him or her to specialty care management.

If a member is pre-certified for elective surgery, the health advisors make an outreach call to provide him or her with information on the surgical procedure, answer any questions about what to expect, the typical length of stay, and suggest questions to ask the doctor, Hummel explains.

The health advisors get in touch with any member who is discharged from the hospital to ensure that they have everything they need and that they understand their discharge instructions. The health advisors can send the members health care information through a secure e-mail service or through standard mail.

"They talk to their member about everything from medication regimes to preventative measures such as exercise, nutrition, to care for catastrophically injured patients," Hummel says.

The Health Advisor program is a "high-touch" model with more member interaction than traditional care management models, Hummel says.

Members who may be confused about the various services their employee benefits plan offers can call their health advisor and ask questions.

The health advisor can help with pharmacy issues, screen for depression, and connect the members with behavioral health services if they are needed.

The health advisors use an electronic portal developed by CIGNA that shows them all of the employer information, including the benefits structure, copay information, and all external partners of the employer group.

"This is a complex process and takes a lot of work to ensure that information sharing across programs is protected and complies with HIPAA [Health Insurance Portability and Accountability Act] and other privacy regulations," Hummel says.

The nurses who work as health advisors are CIGNA’s most seasoned nurses within the service centers.

"We are looking for a diverse set of backgrounds so we have clinical and business expertise. We try to get a mixture of different clinical specialties, such as intensive care, home health care, maternity, or oncology to pull together a powerful team to meet the individual’s specific health care needs," Hummel says.