Redesign puts CM programs under one umbrella
Aim: Members to receive proper interventions
BlueHealthConnections, a care management program in use at Blue Cross Blue Shield of Michigan in Detroit, pulls together a lot of care management programs that have been in place for many years.
"We had case management, we had disease management for a few customer groups, and we had a nurse line. But we knew there was greater potential for the program if we could integrate these to reach more members in need," says Kevin Kihn, RN, project manager for medical care management.
The new program allows patients to move along the continuum of care as needed.
"It depends on the degree and circumstances
of the case. If there is a need for more intense support services and coordination, then a patient with a chronic disease may be shifted from disease management to case management," says Thomas Ruane, MD, medical director of preferred provider organizations and care management.
The team is refining the best points in the spectrum of care where the various types of patient intervention should be done.
For instance, case management has remained a distinct component because of its complexity and the severity of the conditions being treated. Disease management and nurse outreach programs are becoming more integrated and typically focus on
a particular condition.
The program concentrates on four diseases: diabetes, systemic heart disease, congestive heart failure, and asthma. The four conditions represent a significant amount of morbidity and mortality for the population, Ruane says.
"We decided to have our nurses who have been experts over the years in delivering components of the program to take all their knowledge and expertise, meld it with the expertise of specialized vendors to incorporate this wealth of knowledge into BlueHealthConnections. The idea is to seamlessly provide services that address everything from the simplest questions to the most complex problems," Ruane says.
For instance, if a member has diabetes that is severe enough for an intervention, he falls into case management.
The case managers talk to the member and the member’s physician, coordinate a treatment plan, and work with the physician and the member to address his or her health care needs.
In the case of diabetics whose condition is not severe, case management of the interventions may be handled by other components of the program.
For example, the data may show a diabetic patient with coronary artery disease who is not on a lipid program. In this case, a disease management nurse would arrange for the patient to get his cholesterol check and work with his primary care physician to see that he gets treatment.
"Nurses in a disease management program or in a health-line type of setting can effectively deliver those kinds of messages," Ruane says.
In the case of a diabetic with a wound that won’t heal, the nurse counselor who answers the 24-hour call line may be able to give the member suggestions and turn the case over to the disease management nurse if it seems warranted.
"We’re available to answer questions, and we try to develop a relationship with members. We might asks if it is OK if we give them a call in a couple of days to see how things are going," Kihn says.