Multifaceted approach manages Medicare patients
Multifaceted approach manages Medicare patients
Combines disease management, case management
Using a multifaceted approach that includes telephone communication, ongoing education, and case management services, CIGNA Health Care is providing a disease management program for Medicare beneficiaries in Georgia with complex diabetes and congestive heart failure.
The program is designed to integrate disease management with intensive case management interventions. CIGNA is participating in the Centers for Medicare & Medicaid Services (CMS) Chronic Care Improvement Program (CCIP), a three-year project to identify more effective ways to manage chronically ill patients.
At the conclusion of the three-year project, CMS will compare the experiences of the health plans and identify best practices.
The project draws on CIGNA’s experience in disease management and case management, according to Pamela Mays, RN, MPH, assistant vice president for care management for the Bloomfield, CT, health care organization.
"This initiative allows us to take our disease management experience and expertise in case management to the chronically ill Medicare patients fee-for-service population," Mays says.
The company has provided disease management services for its members working in conjunction with American Healthways, a Nashville, TN-based disease management provider, since 1997. The collaborative efforts have been successful in providing improvements in quality care and favorable cost outcomes for 90,000 congestive heart failure patients and 185,000 diabetes patients in its commercial plans.
Types of interventions
CIGNA has operated a Medicare HMO in Arizona for several years.
"When you put together our disease management track record, our experience with Medicare patients, and our case management expertise, they combine to give us the opportunity to improve the quality of life and outcomes for these chronically ill patients," Mays says.
The savings for the program will be measured by comparing patients in the chronic care improvement program to the control group. Patients for both groups were chosen randomly.
The program combines disease management, traditional telephonic case management, field-based case management, and a provider-relations component, to build support within the physician community. "We recognize that it is clearly important to engage with the physicians to ensure the best health outcomes. The program includes education, the application of information on the patient’s disease to everyday life, and the ongoing support of the physician care plan," Mays says.
In addition to telephonic interventions, field-based case managers may visit with patients confined to residential facilities and physician offices whenever possible.
"A lot of the program is about education and facilitating the best possible health outcomes," Mays says.
The company’s traditional disease management and case management services have been enhanced to meet the needs of the geriatric population, who often have age-related challenges that are not strictly medical, Mays says.
"Our model is designed to provide an integration of physician and community-based services to support the overall management of the patient’s condition, in order to address not only disease-specific risk but the risk factors and to improve end-of-life care," she says.
For instance, a social worker will be available to evaluate social risk factors to determine if there is a deficit.
For their project in Georgia, CIGNA officials have enlisted the help of physician leaders, leaders in nursing homes, hospice organizations, and other community-based organizations.
"We feel this is our opportunity to contribute to the integration of services for the elderly in Georgia," Mays says.
The program is strictly voluntary, giving the members the option to drop out at any time.
"This is not a traditional HMO offering, with lists of preferred providers and hospitals in a network. It’s a special design created especially for the Medicare Chronic Care Improvement program," Mays says.
CIGNA is using predictive modeling and assessment tools to help determine the level of interventions each patient requires to support his or her needs.
"The services a patient will receive depend on a holistic assessment of the patient, including the evaluation of cognitive function, a patient’s willingness to engage with the nurses, and patients’ understanding of their condition," They may need outpatient or community-based services or even end-of-life management. Our goals and objectives are to provide the most appropriate outreach for each patient based upon their health status," she says.
American Healthways is providing the disease management interventions, using disease management nurses with expertise in telephonic disease management and care of the elderly.
The disease management nurses will call the patients identified by CMS as eligible for the program, asking them if they want to participate.
They will work closely with the patients’ individual physicians to create a care plan.
In addition to the traditional telephonic case management, the program will have field-based case managers who will go to nursing homes to assess patients.
"Their responsibilities will include the engagement of community and physician services. The physician awareness and involvement in the CCIP is of paramount importance. In supporting the physician care plan, our involvement will work to coordinate all community-based health services available to the patient," she says.
"Regardless of the setting, we will work to engage patients in the program to ensure the best possible health outcomes," Mays says.
In some cases, the disease management and case management nurses may work with legal guardians.
"Our case management staff will have working relationships with the physician and community services. Whether telephonic or in the field, the goal is to have strong working relationships with resources within the project service area," Mays says.
All of the nurses in the program have expertise in geriatric care, including knowledge of chronic illnesses in the geriatric population, and knowledge of the agencies available in the community.
"The nurses will utilize their assessment tools, the information they gather to support the engagement as well as the integration of services to meet the patient needs," she says.
For instance, if a patient is not compliant, the field-based disease or case manager will work with the patient to eliminate any barriers to care.
"Our intent is to support the education, compliance, and integration of services for the patient regardless of what setting they are in," Mays says.
For instance, a patient in a nursing home may be dehydrated, a condition that could result in hospitalization. The case manager can work with the patient and the nursing home and set up hydration for the patient in his or her current setting, avoiding an unnecessary hospital admission.
"When someone leaves a residential facility and is admitted to the hospital, it can be quite traumatic. Therefore, there are advantages to providing services in the patient’s current setting," she says.
The predictive modeling and initial nurse assessment will determine whether the patients are best served by case management in addition to disease management.
"It is a continuum in which service is being aligned with need. The disease management nurses may refer the patients for intensive case management if necessary and vice versa," she says.
The telephonic case management and disease management nurses all are working on the same clinical information system, making it easy for them to share information and refer people from one to another.
American Healthways is building a dedicated telephonic unit in its Baltimore facility to the initiative.
In addition, CIGNA is hiring management staff and field-based case managers in Georgia.
Using a multifaceted approach that includes telephone communication, ongoing education, and case management services, CIGNA Health Care is providing a disease management program for Medicare beneficiaries in Georgia with complex diabetes and congestive heart failure.Subscribe Now for Access
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