Take personalized approach to disease management
Take personalized approach to disease management
Interactions are geared to needs of the individual
A customized disease management program for self-insured employers has resulted in an average 36% reduction in total cholesterol levels for employees in the coronary artery disease program, a 21% reduction in hemoglobin A1c levels among individuals in the diabetes program, and a 51% improvement in blood pressure readings for participants in the hypertension program provided by Focused Health Solutions Inc.
"A close working relationship between the RN disease management coaches and the program participants is key to the success of the program. We have made a concerted effort to design our programs in a more patient-central manner and less in a disease-specific manner. Our nurses focus their interactions with participants so they adopt the best practices of self-care and are motivated to improve their health," says Randy Granata, RN, BC, MSN, clinical educator for Focused Health Solutions programs.
The RN coaches are experienced clinicians who are trained in listening skills and interviewing techniques.
"The reality is that all patients can choose whether or not to follow the recommendations of a health care professional. Addressing patient motivation is the key if we want to improve self-care efforts," she says.
When an employee qualifies for a disease management program, he or she works with a disease management nurse who conducts an additional assessment of the employee's overall risk.
The individual's acuity or overall risk level determines the amount of time the nurses spend working with the participant and increases with the acuity of the individual.
The program utilizes an opt-in model, which means that individuals are motivated to participate, she points out.
When employees enroll in one of the disease management programs, a nurse assesses them to determine how well they are doing in terms of self-care and where the gaps in care occur.
The nurse coach obtains the patient's medication program and clinical data, such as laboratory values; determines how well the employee is adhering to his or her treatment plan; assesses behavioral gaps in the area of self-care; and develops a collaborative plan with the employee.
For instance, if the employee has hypertension, the nurse determines if he or she monitors blood pressure regularly. They find out if someone with asthma uses a peak flow monitor regularly, has filled his or her prescription for a short-term reliever medication, and has an asthma action plan.
The interventions are member-specific and based on gaps in care and health care behavior.
In addition to the regular telephonic coaching sessions, the nurses e-mail their clients educational information related to the issues they are addressing. For instance, if an employee isn't taking his or her medication, the nurse sends a link to information that stresses the importance of medication compliance for that particular condition.
The company provides participants with the tools they need to monitor their health. For instance, it sends people with asthma a peak flow monitoring device and the nurse teaches them how to use it.
Members who are at the highest risk level are provided with a telemonitoring program that enables them to transmit secure biometric data to their nurse.
"They use the equipment to transmit information daily, and we use it to trend how they are doing and gear our interventions to meet their needs," she says.
A customized disease management program for self-insured employers has resulted in an average 36% reduction in total cholesterol levels for employees in the coronary artery disease program, a 21% reduction in hemoglobin A1c levels among individuals in the diabetes program, and a 51% improvement in blood pressure readings for participants in the hypertension program provided by Focused Health Solutions Inc.Subscribe Now for Access
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