Select where you can have impact on cost, utilization
Develop your DM program one step at a time
When ConnectiCare of Farmington, CT, set up its disease management programs, the staff looked carefully at its covered populations and chose programs that were prevalent and had high emergency medical utilization.
"We looked for conditions where there was a set of nationally recognized guidelines that could guide the care, and conditions where we felt we could make an impact," says Jay Salvio, BSN, MBA, director of ConnectiCare’s health management department.
For instance, there are 23,000 people with asthma in the ConnectiCare population. "There are nationally recognized guidelines for asthma, and we know that proper management can have a significant impact on the quality of life for people with asthma," adds Steve Delaronde, MPH, MSW, an epidemiologist/research analyst for the health management department.
There weren’t as many members with heart failure, but there was enough utilization in the membership and ConnectiCare was adding a managed Medicare product to its line so the staff felt they could make an impact, Salvio says.
Here’s how ConnectiCare selects areas where a disease management program could have an impact:
It looks at the membership for the top diagnoses and procedures, where there are the most claims, what disease and conditions are most prevalent, and what costs are associated with the conditions. From there, it looks at which conditions a disease management program could impact the most, including reduction in hospitalization, emergency department visits, and improvement of quality of life.
Once you target a disease or condition for a disease management program, you should learn as much as you can about the condition and how it’s treated. "If you’re going to educate and impact your membership, you need to be knowledgeable about the condition and know how to apply the treatment protocols to your membership," Delaronde says.
You must be certain that you can identify members who will benefit from the intervention and that you can stratify them as to level of severity to determine who needs help the most.
For instance, it would take an enormous staff to contact all 20,000 of ConnectiCare’s members with asthma, assess, and educate them. That’s where the stratification piece comes in.
"We’ve identified the members whose conditions have brought them most often to the emergency room or inpatient hospital. These are the people who will benefit most from case management," Delaronde says.
These patients were offered the opportunity to enroll and participate in the program.
"Once we know we can stratify our membership, we can put together our own disease management plan that will work for our population," Delaronde says.
Then decide how you’ll go about managing them and how frequent the management will be.
"What we have learned is to develop a protocol that sets out exactly how you are going to work with your members. You should know what topics the intervention is going to include and how long it is going to last. Your goal should be to cover certain topics and provide a certain number of interventions over a certain period of time," Salvio adds.
However, there is no hard and fast prescription of what interventions are needed for every patient.
"Some members need more education. Some grasp things very quickly and are dedicated to managing their disease," Salvio points out.
A good disease management program should include a management plan that specifies the intensity of contact and how the members will be contacted.
"You need to have in place a plan for how often you’re going to call the members, even before you know who you are going to call," Salvio says. (Click here to see graphs 1 and 2.)
Eight things to consider in developing a DM program
1. What population will you manage?
2. Will management be one-on-one or population based?
3. How will you contact the members?
4. What tools will you use?
5. What collateral material, such as newsletters and educational pieces, will you need?
6. How often will you contact the members?
7. How long will they stay in the program?
8. How will you determine the effectiveness of the program?
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