As the cost of health care continues to soar, employer groups and
health plans are focusing on wellness programs that help people
who arent sick now change their lifestyles and avoid developing
chronic diseases, such as emphysema, heart disease, or diabetes.
The health care system is beginning to take a more proactive, rather
than a reactive, approach since we know that preventing illness is much
more cost-effective than treating illness, says Connie Commander,
RN, BS, CCM, ABDA, CPUR, president of Commanders Premier
Consulting Corp. and past president of the Case Management Society of
America.
In the past decade, the health care system has offered disease management
programs for people with chronic diseases to help them stay
out of the hospital, but there havent been many programs that support
people who are trying to stay well and take the next step to quit smoking,
start exercising, or lose weight, says Cary Badger, MPH, vice president
of market development for Regence BlueCross Blue Shield.
The emphasis among insurers is shifting more to consumer engagement
and away from managing the patient. We want to empower the
consumers to become an active partner in their health care decisions,
Badger adds.
Regence has launched a program called Activate that allows participants
who engage in healthy behaviors to earn up to $600 a year that
can be applied to their deductibles and co-pays. (For details on the
Activate plan, see related article on page 51.)
When health care costs were absorbed by employer groups and the
consumer paid significantly lower out-of-pocket expenses, the focus
was not on prevention and wellness as it is today. Individual consumers
wanted to be healthy but were not financially vested in the process. But
now that the health care system is facing a financial crisis and health
care premiums are rising, people are paying attention, Commandersays.
There is an increasing emphasis on healthy
living and prevention in the health care arena.
Employers and health plans have been spending
a lot of money on unhealthy employees. Now
theyre looking at offering programs that can prevent,
rather than treat, illness, Commander says.
The shift in emphasis from curing illness to
educating people on how to stay healthy is a
great opportunity for case managers to make a
difference to their clients, Commander adds.
As case managers, a lot of what we do is
teaching. This gives us the opportunity to share
knowledge about healthy choices and give consumers
information they can use to motivate
themselves and embrace changes, she adds.
No matter what setting they practice in, case
managers have the opportunity to teach their
patients or clients about healthy behavior no
matter what the initial reason for the contact, says
Catherine M. Mullahy, RN, BS, CRRN, CCM,
president and founder of Mullahy & Associates, a
case management training and consulting
company.
We cant spend all our health care dollars on
sickness. Many practice settings for case managers
focus on illnesses, but nurses are grounded
in promoting health because of our orientation
and education. We have to take a proactive
approach and help people stay healthy and avoid
needing health care interventions, she says.
Its all a part of advocating for your patients,
Commander adds.
Part of the case managers goal with an individual
with an illness or condition is to empower
them to take care of themselves. If we include a
wellness component in the self-care education,
we can help them improve their outcomes and
avoid a recurrence, she says.
Getting someone to stay well is no different
from motivating someone to take their medication
for diabetes, Commander adds.
Most people need a hands-on approach, and
we need more case managers on the front line
helping people adopt healthy lifestyles, she
says.
Case managers have so many teaching opportunities
when they work with their clients,
Mullahy points out.
The entire conversation doesnt have to be
about the illness. They can encourage people to
return to normalcy by adopting a healthy way of
living, she says.
Mullahy advocates integrating wellness efforts
into disease management and case management
programs.
Whether case managers are capturing people
in the initial stages of a chronic illness or assessing
them for something like orthopedic surgery,
they can educate them about behavior that will
keep them healthy, she says.
For instance, when Mullahy owned a company
that provided case management services, her case
managers recorded every clients height and
weight, no matter what the diagnosis, and determined
his or her body mass index (BMI). If the BMI
was not within normal range the case managers
counseled patients about healthy lifestyle changes.
Case managers should take every opportunity to promote wellness by looking for teachable moments and embracing them, Commander says. For instance, when you are working with diabetics to get their conditions under control, educate them about healthy habits that can help their children avoid developing the disease, she says. When case managers work with a client, they can take the opportunity to talk to the entire family about healthy activities, she says.
Hospital case managers are particularly challenged to approach patients with wellness information because the patients whose care they manage are very sick, Mullahy says.
We need to create a balance between getting people out of their medical crisis and promoting good health, Mullahy says.
Keep in mind that when people are recuperating from a serious illness or injury, it may not be the best time to tell them that an unhealthy lifestyle was what put them in the hospital, Mullahy warns.
However, a health care crisis can plant the seeds of healthy lifestyle changes, she adds. Its more effective to ease people into a healthy lifestyle as they are headed toward the road to recovery, she says.
Patients may promise themselves that if they get through the crisis, theyll change. Case managers need to be aware that while these promises are well intentioned and patients may be able to sustain their commitment for a time, they may fall back into their usual habits, she says. Its wise for a case manager working with a patient who says hes learned his lesson and plans to exercise and watch his diet to recognize that human behavior is likely to take him back on the same road, Mullahy says.
Congratulate them and encourage them for their resolve to mend their ways, but recognize that their commitment may diminish over time and reconnect with them to continue to reinforce their good habits, she suggests.
No matter what setting in which they practice, case managers have the opportunity to refer their clients to programs that can help them stay healthy, Mullahy says.
Most case managers are not in the business of wellness, and often their caseloads dont allow them to spend a lot of time on healthy behavior, but they still can educate patients about the wellness and fitness plans available through their hospital, their health plan, their employer, and in the community in hopes of moving them into a healthy way of living, Mullahy says.
Some resources may include wellness programs offered by health plans and employer groups, hospital-sponsored weight reduction, smoking cessation, or aerobics programs as well as low-cost programs at community agencies such as the YMCA and online programs such as Weight Watchers.
Health plans and employer groups are offering health promotional programs, including discounts for gym memberships or weight loss programs or economic incentives to enroll in a healthy living program, as well as wellness and prevention pieces, in addition to disease management and case management programs, Commander points out.
Now that people are experiencing higher deductibles and co-pays, we may find that they are going to try to stay healthier and avoid going to the doctors office. All of us in the health care field know that when people access the system, it costs a lot of money. Now, we have to come up with ways to motivate individuals to have a healthy lifestyle, she adds.
Members earn rewards for healthier lifestyles
Points can be applied to deductibles, co-pays
As part of its efforts to promote healthy living and save health care dollars in the long run, Regence BlueCross BlueShield is rewarding members for adapting healthy lifestyles. The company has introduced Activate, a selfmanaged health care plan that allows members to earn points for engaging in healthy behaviors and convert the points to Member Choice Funds, which they can use to pay deductibles, co-pays, or other out-of-pocket expenses.
Employers today want to help their employees adopt healthier lifestyles. Activate encourages members to become active partners in their health care and rewards them directly for that behavior, says Cary Badger, MPH, vice president market development.
Members enrolled in Activate can collect up to $600 a year in Member Choice Funds that can be applied to their deductible or co-pay. Members automatically get 200 points when they complete a health risk assessment.
They can earn additional points for 75 different activities, ranging from enrolling in a smoking cessation or weight loss program to getting a flu shot or attending a healthy cooking class to visiting web sites that offer healthy living advice. If they log on to the sites through myRegence.com, their visits are automatically tracked and added to their personal choice account.
The program primarily works on the honor system. If a member reports participating in an activity that qualifies, he or she accumulates the points.
If members dont use their personal choice points, they roll over to the next year. Regence introduced the program at a time when many employer groups are offering their employees health care plans that have higher deductibles and co-pays than in the past. A$1,500 deductible is not uncommon among employer groups insured with Regence, Badger says.
When people know they will be rewarded for healthy behavior, it makes the increased deductibles and co-pays easier to accept, he adds. To help employees stick with their healthy behavior, the Activate program, along with other Regence plans, offers members access to a health coach, a 24/7 nurse line, and the Special Beginnings maternity management program. In addition, they belong to the Regence Advantages program, which offers discounts on hearing aids, fitness club membership, weight management programs, and other health-related activities. Regence members have access to health coaching and online nurse advice even if they dont sign up for the Activate account on myRegence.com. (For details on how the health coaching program works, see related article, right.) The wellness program is integrated with disease management and case management.
Activate builds the wellness component into the overall program. The rewards system allows members to immediately see the results of their healthy behavior, Badger says.
The program is a win-win for the employers, their employees, and the health care system as a whole, Badger says.
Our Activate program returns money to consumers when they start healthy behaviors. Even though the savings wont materialize quickly for the employer and the health plan, we know that it will lower health care costs in the long run, Badger says.
Employees become active and feel better; they have fewer illnesses and miss less work, which translates into a healthier bottom line for the company, he adds.
Its hard to calculate an immediate return on investment for wellness programs, Badger points out.
If a person quits smoking today, we may not see results in his or her health care utilization for 10 years or so, but in the long term, its the best for the person and the health care system, he says.
Regences health care cost trends have steadily decreased since 2002 when the company began offering incentive programs that have encouraged their employees to lose weight, quit smoking, and engage in other healthy behaviors, Badger says.
Regence began offering the Activate program to insured groups in mid-2008 and doesnt yet have outcomes data. However, the program has gotten rave reviews from participants, he says. Members have told us that they like the idea of receiving immediate recognition for trying to change their health, he says.
Coaches help members make lifestyle changes
Emphasis is on keeping them healthy
When members at Regence BlueCross Blue Shield want to lose weight, start exercising, quit smoking, manage the stress in their lives, or get a good nights sleep, help is just a phone call away.
The Portland-based health plan offers health coaching at no charge as part of a suite of member benefits designed to help members maintain a healthy lifestyle.
Its all a part of Regences emphasis on keeping members healthy now to avoid health care costs in the future, says Loralee Trocio, MPH, supervisor health coach program.
The program is available to all Activate members, whether or not they have a chronic condition or any other health care problems. However, the health coaches work closely with the health plans disease management and case management department to ensure that all the needs of a member are met.
We emphasize all the different resources available through their health insurance plan. In some cases, the members may also benefit from working with a disease management nurse, a case manager, or even a behavioral health specialist. If we identify a service the member could benefit from, a referral is made to that program, she says.
The health coaches work closely with other departments at Regence and sometimes co-manage members. For instance, a health coach working with a member with diabetes may refer the member to disease management.
Members who sign up for the Regence Health Coaching Program work one on one with a personal health coach over the telephone or through e-mail on any of five tracks: tobacco cessation, stress management, weight loss and nutrition, exercise, or help with sleep.
The tracks are determined by the individual based on what the member would want to achieve and the goals he or she wants to set. People have an idea of what they want, but its a matter of getting specific, Trocio says. The goal of the program is to give members tools and skills to work toward behavioral changes that promote a healthy lifestyle, which they have defined for themselves. Members typically work with a health coach for twelve 45- minute sessions over a period of three to six months.
The health coaches help the members set smart goals, which are specific, measurable, action-based, realistic, and timely objectives. For instance, a general goal is Id like to be more physically active.
A smart goal is: Im going to run two miles after work on Tuesday and Thursday. If they are still contemplating changing or implementing an exercise routine, we address their stage or readiness and help them work toward taking action, Trocio says.
The health coach helps the member identify any obstacles he or she has encountered in the past and develop strategies to overcome them. They work with the members to help them become aware of the strengths they can build on while reaching their goal, she adds. The health coaches have a variety of backgrounds but all have earned verification as a wellness coach.
The health coaches work closely with the case management and disease management departments at Regence and sometimes co-manage members.
For instance, a disease management nurse working with a member with diabetes may refer the member to a health coach.
The disease management nurse would educate the member about how to check his or her blood sugar, how to take insulin, or what specific diet to follow. The health coach would help them set goals around the diet or physical activity recommended by the nurse.
We partner with each other to meet each others needs, she says.
Demonstration project improves outcomes for ill
CMs work with patients by telephone and face to face
A Medicare demonstration
project in Florida that includes both telephonic case management and
face-to-face interventions has improved clinical outcomes for
beneficiaries who are eligible for both Medicare and Medicaid and have
congestive heart failure or any combination of comorbidities that
include congestive heart failure, diabetes, and coronary artery disease.
The program, which started in 2005, has been so successful that the
Centers for Medicare & Medicaid Services (CMS) has extended its contract
with LifeMasters Supported SelfCare, an Irvine, CA-based provider of
health improvement services.
"The program has
demonstrated cost-effectiveness to Medicare, and our preliminary
analysis indicated that we have improved the clinical outcomes for a
very difficult-to-manage population," says Christobel Selecky, CEO of
LifeMasters. The goal of the program is to reduce preventable
utilization with a combination of health coaching and lifestyle changes,
Selecky says. CMS is measuring the outcomes for the group that
LifeMasters is managing against a control group.
There are about 28,000
participants in the program.
"We are showing good
results in our population compared to the control group and are slightly
above break-even for the new cohorts in the program. People who have
been in the program since it began in 2005 are getting older and sicker
and experience higher health care costs than the new participants,"
Selecky says. May 2009 / CASE MANAGEMENT ADVISOR 53 Participants in the
disease management program are followed by nurses in a call center
called clinical nurse consultants (CNCs) and/or community-based case
managers called community service RNs (CSRNs) who work with the
beneficiaries in their homes.
"The team in the field
and the team at the call center are extremely tightly integrated and
refer back and forth to each other," Selecky says. Referrals for the
program come into the call center where specialists complete an
evaluation and determine if the person's care could be coordinated over
the telephone or if they need face-toface care, says Vicki Manning, RN,
community services RN team manager.
"It's a seamless system.
If the clinical nurse consultant at the call center has concerns about
one of the participants, they send a referral to the community service
RN or social worker to evaluate the participant in their home," she
says. (For details on how the community-based program works, see related
article on page 55.) "LifeMasters' goal is to manage as many people as
possible by telephone because successful programs need to be scalable.
However, to ensure that all participants are getting the help they need,
different options must be provided," Selecky points out.
About 30% of the
participants have had a faceto- face visit with a LifeMasters nurse at
least once, but only about 94% of them are followed regularly by the
clinical nurse consultants in the call center. "People tend to have the
preconceived notion that a telephonic program won't work with older or
underserved participants, but it does work if there is an outlet for
other interventions when required," Selecky says.
When CMS sends
LifeMasters the names of individuals eligible for the program,
LifeMasters contacts the beneficiaries and invites them to participate
in the program, then sends a letter to their primary care physicians
explaining the program. The participants are assigned a nurse who calls
them on a regularly scheduled basis. "The frequency of contact depends
on the severity of the individual's conditions. Many of the participants
are not accustomed to focusing on their health, and the nurses may
gradually ease them into managing their condition," she says. Selecky
attributes part of the success of the program to a unique method of
stratifying participants, a combination of traditional stratification
based on utilization and cost of care with the Patient Activation
Measure, a tool that assesses an individual's likelihood to engage in
making health care changes.
In the past, disease
management programs have stratified people primarily based on their
utilization and the cost of their care. We are being held accountable
for reducing health care costs, and we need to give priority to the most
severe. However, over the past year, we have implemented a new way of
further stratifying participants based on their activation level, she
says. The Patient Activation Measure assesses a persons knowledge,
skills, and confidence in playing
a role in their own
health care and ranks them in one of four activation levels according to
their engagement in health care.
We have researched this
method and found that if the nurse tailors the conversation according to
what level of activation the person is at, we can make a dramatically
different impact, she says. The nurses use the results of the Patient
Activation Measure and
the participants level of severity to gear their encounters, using
motivational interviewing techniques.
For instance, patients on
Level 1 of the activation scale feel they can make no impact on their
own health. Therefore, trying to persuade them to get a lab test may be
a waste of time. Instead, the nurses help them understand how they can
have an impact on their
own health and move them toward the next level of activation. Research
shows a correlation between the level of activation and actual
self-care. If we focus on moving them out of the activation level, they
start to show behavior that drives improved outcomes, she says.
The combination of
motivational interviewing and patient activation has resulted in much
better retention in the program because the participants arent
frustrated by being asked to do things they arent ready to do, she
says. Because understanding a participants current clinical status is
important to avoid costly but preventable exacerbations, LifeMasters
provides the tools that the participants need to use to take and report
their vital signs and symptoms on a daily basis. The congestive heart
failure patients receive a scale and a blood pressure cuff, and the
clinical nurse consultants teach them to enter data on weight, blood
pressure, and other vital signs through the Internet or through a
touch-tone phone.
The information they
input goes into our system, where it is measured against national
guidelines. If the system flags someone with 54 CASE MANAGEMENT ADVISOR
/ May 2009 signs that could signal a clinical exacerbation, the
nurses call them and find
out whats going on, she says.
In about half the cases,
the nurse identifies a behavioral reason for the out-of-bounds event and
uses the call as a teaching moment. For instance, a patient might be
having symptoms of an exacerbation because of non-adherence to the drug
regimen. If the nurse cant determine a behavioral reason for the
problem, the system creates an alert that is
faxed to the physician
for follow up. LifeMasters has tested combinations of approaches with
participants to see which
method works best in
getting people to participate at the appropriate level.
We know from our own
research that if you compare people who have a regular relationship with
a nurse to people who get just a newsletter and periodic follow-up,
there is an improvement of several hundred dollars per member per month
in cost savings. Obviously, it is worth it for us to deploy a lot of
resources to find ways to engage patients, she says.
Different approaches
include sending an introductory piece to a family member or physician
instead of the participant and whether to have a nurse or a non-nurse
make the first call. We have good enrollment and good engagement in
the program. Research has led us to expect that about 20% of
participants in our standard populations would be highly engaged and
willing to monitor their vital signs and interact with the nurse on a
regularly scheduled basis. In this group,
about 35% are highly
engaged, a substantial percentage for this population, she says.
Face-to-face interventions help chronically ill
George is a 67-year-old
man with diabetes, cardiac problems, and asthma who takes more than 10
medications. He is insulin- and oxygen dependent, lives alone, and is
illiterate.
When Vicki Manning, RN,
began visiting George in his home as part of the LifeMasters Supported
Self-Care Medicare demonstration program for dual-eligible beneficiaries
with multiple chronic illnesses, it took several sessions to build up
enough rapport for George to admit that he never learned to read and
write. Using pictures and drawings, Manning taught George about his
illness and how to manage his medication and treatment regimen. She drew
symbols on his medicine bottles and on a chart to help him learn when to
take each medication.
After six months of
regular visits, George was able to take his medication regularly. He
could monitor his blood pressure and heart rate and follow the
parameters set by his physician to call in to the doctors office when
they reached a certain level.
He could check his blood
sugar and give himself a regular dose of insulin as well as following a
sliding scale to increase or decrease the dose based on blood sugar.
I taught him how to
access community services in his area and to visit a food pantry or call
a hotline when he needs help paying his electric bill, says Manning,
now team manager for LifeMasters community services RN team. Georges
story illustrates the effectiveness of face-to-face encounters in
empowering people with multiple complex conditions to take charge of
their own health care.
The majority of
participants in the LifeMasters demonstration project are managed by
call center nurses, called clinical nurse consultants. The community
services RNs (CSRNs) are called in when the participants have a positive
score on a frailty screening that identifies that they may be at risk,
when they have had a recent fall, have been hospitalized, have vision or
memory problems, take multiple medications, report an increased need for
assistance in the home, or have multiple complex conditions.
The CSRNs also visit
participants who do not have telephones and arrange for them to have
free wireless telephone service that they can use for emergencies and
telephonic intervention. If we get them stabilized, then they can be
followed through the call center, Manning adds. When participants are
hospitalized, the CSRN visits them in the hospital and collaborates with
the discharge planning team to ensure a smooth transition home. When
participants are in a skilled nursing facility or assisted living
center, the CSRNs visit the participants in the facility and partner
with the staff to manage the care of the patients.
When a participant is
referred to the community services RN team, a nurse makes a home visit
to determine the persons needs and level of ability to self-manage his
or her care. We look at medication adherence, functional ability,
safety, housing, financial concerns, nutrition, transportation, and any
care deficits and support systems. Our goal is to give participants the
education and support they need to empower them to take an active role
in their care,h Manning says.
The dual-eligible Medicare
and Medicaid population faces tremendous hurdles in learning to manage
their own health care, Manning says. Participants in the program are low
income and often have problems paying for housing and food, let alone
their medication or the healthful foods that are recommended for people
with their chronic conditions, she says.
Many dont go to their
physician appointments because they dont have a way to get there. The
nurses work as a team with social workers to identify community
resources that can provide medication assistance, transportation to
medical appointments, and help with housing or utilities. They assist
the participants in identifying unnecessary expenses in their budgets,
such as paying top rates for phone service when less expensive service
is available.
We work to meet their
basic needs such as food and shelter before we tackle the medical
issues. We are creative in helping participants find the resources they
need. If we get food on the table, then perhaps theyll be open to
monitoring their blood pressure, Manning says.
The nurses tailor the
in-home visit to the participants needs, their abilities, and their
support system. Some require weekly visits; at a minimum, the nurses
visit the participants at least every 30 days.
The team includes
bilingual staff who speak English, Spanish, and Creole and who have
access to a language line that provides interpreters for a variety of
languages.
Literacy is a huge hurdle
in this population, and often, participants have a discomfort level in
revealing this information to the staff, Manning says. One way the
nurses address the problem is to put pictures and symbols that the
participant can relate to on their medication models so they will know
what the medication is for and when to take it.
The nurses and social
workers are assigned geographically by zip code and carry a caseload of
40 to 55 participants. They use wireless laptop computers to enter
information on the LifeMasters system, which is shared by the call
center nurses, giving both instant access to patient information.
Take on a bigger role in
workers compensation
Health managers should focus on business component
A newly hired occupational health nurse knew intuitively what she was saving her company, but lacked quantifiable numbers. To come up with hard data to show her worth, the nurse turned to her workers compensation carrier. We put together a report for the nurse that illustrated the frequency and individual and aggregate costs of the companys claims, says Christine R. Zichello, RN, COHN-S, CSHM, ARM, FAAOHN, senior risk control specialist at PMA Insurance Groups Mount Laurel, NJ, office. It was clear that lost time and injury claims, with the resulting loss of productivity, had been costing the company a considerable amount of money. The insurer was able to show that since the nurse came on board, the company had seen a 91% decrease in the frequency of claims.
Getting employees back to work more quickly, reducing the frequency of claims, and identifying high-risk areas: To get eye-catching results for any of these areas, you need a solid grasp of the workers compensation process.
As the economy continues to change, organizations are looking more and more at the bottom line, says Zichello. You can actually save money for the company by becoming actively involved in the workers comp process.
As insurance companies focus more on disability management and the medical aspect of workers compensation, you need to diversify yourself, says Denise Zoe Gillen-Algire, RN, BSN, MBA, COHN-S/CM, FAAOHN, president of the Workers Compensation Association of New Mexico and practice leader for Integrated Health and Productivity Management at Risk Navigation Group, both in Albuquerque, NM. If you are not involved in this realm of the business, you need to be, says Gillen-Algire. Understand not just the clinical component, but also the business component and the employers perspective.
Track claims by your companys top injury codes by frequency, and also top injuries by severity in terms of total claims dollars incurred. The focus should be not only on the frequency and severity, but also on the potential for highdollar claims, says Gillen-Algire.
You might find, for example, that you usually have more back claims in a particular department or shift. You can turn that information back into your prevention efforts, says Gillen-Algire. If you discover a high-risk area, perform an assessment of what the employees do and how hazards can be eliminated. Go for the low-hanging fruit, says Gillen-Algire. For instance, slipresistant mats can be added to a kitchen area to prevent fall injuries.
To increase involvement in case management of workers compensation claims, Zichello advises obtaining certifications in case management from the American Board of Occupational Health Nurses or the American Nurses Credentialing Center. Armed with these skills, youll be able to verify medical reasons for employee absences, follow up after absences from work, and assist employees with chronic illnesses. Case management assists in the safe and timely return to work and results in cost savings, says Zichello. New opportunities await Your workers compensation carrier can be your ally when it comes to coming up with hard data to show your worth.
Being well-versed in workers compensation also could open up new job opportunities. Early in her career, Zichello was an in-house occupational health nurse for an insurance company. This led to her current position in the risk control department with an insurance carrier.
We were writing a lot of health care accounts, and I saw the connection, says Zichello. As a registered nurse, I know health care and realized that I could make an impact on the bottom line by combining by nursing knowledge and addressing safety issues.
|
COMING IN
FUTURE MONTHS |
| ■ Helping your clients adhere to their treatment plan |
■ Opportunities in
community-based case management |
■ The move toward patient centered
medical homes |
■ Providing culturally
competent case management |
May 2009 / CASE MANAGEMENT ADVISOR
