Case managers interact with members and their families as well as providers.
Case managers interact with members and their families as well as providers.
Explaining continuum of care
"We try to address the issue of continuum of care, explaining to the family why members are at the current level of care, and when and where they should receive care in the future. We work with the discharge planners at the facility to help the member transition between levels of care," King says.
Often, the case managers educate family members about the various levels of care, explaining why patients need to be discharged from the acute inpatient setting and helping them understand what kind of care they will receive at the next level of care.
"We explain why the member needs to go to the next level of care and show them their financial responsibility if they continue to stay in a facility that Medicare won't pay for. We support the hospital decision to discharge when the chart shows that the patient is ready to go. We don't want the hospital discharging people too early because they come right back," he says.
The case managers advocate for the members with the clinical staff in the hospital to ensure that the member receives recommended care.
If a member is experiencing frequent readmissions for the same condition, the case managers intervene and conduct an assessment to determine the cause. It may be that the member doesn't understand the treatment plan or is unable to follow it and needs help from a health coach or a disease management nurse. Or the case manager may find out that the members didn't receive the post-acute services that were prescribed or that they were inadequate, or, in some cases, the patient was discharged from the hospital too soon.
"We try to be as proactive as we can. The more we are involved, the more it's a win-win effort. If we can help members avoid future episodes of care, it reduces health care costs, reduces their out-of-pocket expenses, and improves the quality of life for our members," King says.
The health plan uses a data mining tool to identify members who are eligible for the disease management program and uses a three-pronged strategy to help them manage their conditions.
Low-risk members are those with chronic conditions who are managing well with no gaps in care and no inpatient stays or emergency department visits associated with the condition or disease.
They receive a welcome letter along with a brochure describing the program and regular educational newsletters. The low-risk members also are offered the opportunity to opt in to the program if they think they need support from a nurse. A low-risk member who chooses to opt in to the program might be someone who is concerned because of changes in his or her blood sugar level or needs support to get on a diet and exercise program.
"Our role is to help the members set healthy lifestyle goals and to provide support for the physician's treatment plan," Arneson says.
Members at moderate risk have a gap in care, such as not receiving a cholesterol screening or a hemoglobin A1c test.
"Every quarter, we have campaigns set up that focus on members with care gaps. We encourage them to talk with their provider about evidence-based care guidelines to ensure that our members receive the full range of services to address their health conditions," she says.
All of the disease managers are RNs and have earned the Certified Chronic Care Professional (CCP) designation.
When a member agrees to participate in the disease management program, the disease management nurse completes a disease-specific assessment over the telephone. The assessment includes information about the member's condition, knowledge of his or her treatment plan, and risk factors.
For instance, if the member has asthma, it's important for the nurse to know if he or she smokes, something that doesn't readily show up in claims data.
They screen all members for depression and coordinate their care with the behavioral health team if needed.
The disease management program for high-risk members is individualized. The frequency with which the nurses contact the members depends on the members' needs and preferences.
For instance, if a member has experienced an exacerbation in his or her condition or has started on new medications, the nurse may call in frequently. Then, as goals are met, the nurse contacts the member every few weeks, then every few months.
"We try to address the issue of continuum of care, explaining to the family why members are at the current level of care, and when and where they should receive care in the future. We work with the discharge planners at the facility to help the member transition between levels of care," King says.Subscribe Now for Access
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