CM department scores big on member satisfaction

Multidisciplinary team collaborates on patient care

Blue Cross Blue Shield of Rhode Island's case management department consistently scores in the 90th percentile on satisfaction surveys sent to members who have completed a case management program.

The 2006 surveys show 99% of respondents reported being treated with dignity and respect; 97% rated their experience "good to excellent;" 98% reported being able to reach the case manager by telephone; 93% reported usually or always receiving a return phone call within 24 hours; 93% said the education they received helped improve their health habits; and 96% would recommend the service to family and friends.

The not-for-profit managed health care plan has been recognized by J.D. Power and Associates for providing an outstanding experience to its PPO members and received an "excellent" rating from the National Committee for Quality Assurance (NCQA). In addition, the case management department was one of the first three Blue Cross plans nationwide to receive the highest accreditation from URAC.

The case management department's multidisciplinary team collaborates to provide all the services that members need to learn to manage their health, says Yvette Chartier, RN, BS, CCM, CPUR, manager of case management for the Providence-based health plan.

The integrated case management department includes RN case managers, social workers, dieticians, tobacco cessation specialists, and RN health coaches who are experts in working with members on specific diseases, such as asthma, diabetes, or cardiac conditions. They can call on the medical director, staff pharmacists, and other resources within the company to help meet the needs of the members, Chartier says.

"The nurses in our program have an average of 18 years of clinical experience.

We have nurse case managers on staff who have specialized in pediatric care management, oncology management, and management of transplant patients so they have the expertise to coordinate the care for these patients," she adds.

Having all the disciplines in one department makes it effective for the team to collaborate on patient care, Chartier says. In addition, the health plan contracts with an external vendor for behavioral health services and dedicated behavioral health case manager on site at the health plan.

"Our staff can collaborate with the behavioral health case manager and co-manage members with both behavioral health and medical issues," she says.

The health coaches focus on specific conditions and provide telephone coaching, monitoring, and evaluations.

When members have more than one chronic condition or comorbidities, the team determines whether the member would be better served if the case manager or the health coach was in charge.

All of the staff are cross-trained to handle any needs the members may have, allowing continuity of care when a member's care is being coordinated by one team member and he or she develops an additional condition.

For instance, if a health coach is already working with a member on diabetes control and the member fractures his or her hip, the health coach could continue to manage the members.

The case managers have basic knowledge of community resources, such as medication assistance or Meals on Wheels, but also consult with the team's social workers for additional help.

Members eligible for case management are identified by through health risk assessments, predictive modeling, and claims information triggers that identify patients with certain diagnosis codes, and those who have been admitted to the hospital. Customer service representatives identify issues that members need help with when they talk with members on the telephone and utilization review nurses refer members for case management services.

"We have worked with our provider community to help increase the number of referrals from physicians," Chartier says.

Introducing a member

When a member is identified for case management, a nurse calls them and begins to establish a relationship.

"There is a lot of concern when members get a call from their health insurer. The role of the case manager during this phone call is to explain how we are there to help them navigate the complex health care system," Chartier says.

The health plan contracted with an external vendor to train the case manager on effective ways to educate members about the services that the health plan can offer. "As nurses we are not as comfortable with marketing as we are with patient care. We wanted to give the nurses skills to help them engage the member and see the benefits of participating in our programs," she says.

If the member expresses interest in participating in the case management program, the case manager completes telephone assessment to help the member identify potential areas where the health plan can be of assistance. The assessment includes information on the member's medical condition, medications, and psychosocial, and behavioral issues.

The member is then assigned to the team member who can help with their problems.

"This is where having an integrated team is of benefit. The member might need to speak with the dietician for help with nutrition or may need to work with a social worker to coordinate community resources," Chartier says.

Setting goals

The case managers have been trained on motivational interviewing and readiness to change and use this knowledge to help the members set goals.

The nurses match the members' readiness level to the types of interventions that will benefit them. Many of the goals revolve around providing education about their condition, diet, and exercise. The case managers work with the members on medication compliance, helping them understand how to take medication correctly and to understand side effects.

"We educate the member to talk to the physician for an alternative if they experience side effects, rather than stop taking the medication," she says.

In other cases, the case manager may work with a member who is recovering from a catastrophic injury or undergoing treatment for cancer or another condition. For instance, a member going through chemotherapy and radiation treatment might not understand the treatment regimen and the side effects the medication may cause. The case managers educate the members about what to expect from their treatment and when they should call the doctor if they are experiencing certain symptoms, Chartier says.

"Members who are seriously ill or going through chemotherapy may not be thinking about what questions they should ask the doctor. The case managers are here to help them understand their disease and their treatment and to be prepared so they can make the most of the next doctor's visit," she says.

One of the triggers for referral is when members have had two hospital admissions within a six-month period.

If a member agrees to participate in the program, the case manager contacts the member's physician to collaborate on a treatment plan.

The health plan has made a concerted effort to promote a collaborative relationship with physicians. In 2004, the health plan started reimbursing providers $50 for a telephone consultation. As a result the physician collaboration rate increased from about 23% to as high as 60% some months.

The case manager faxes the physician a form, which lists all the medications the member has reported taking and any other issues or potential problems. "We fax them in advance to let them know that we will be contacting their office within 24 hours and ask them to let us know if there is a better time to communicate with them," Chartier says.

When the case managers call the physicians, they review the medication and make sure the member's self-reported medication plan matches what the physician has on file, such as the member is taking the appropriate dose at the appropriate time.

"Many times, if a member has just been discharged from the hospital, the primary care physician may not be aware of new medication," she says.

The case managers discuss the members' goals with the physician and find out how they can help reinforce the treatment plan the physician has developed.

The average members stay in case management for four to six months, Chartier says.

"At the outset of the relationship, the member sets individual goals and they are discharged from case management when they complete the goals unless they are willing to work on other goals," she says.