Lifeguard initiates care management plan
Lifeguard initiates care management plan
High-risk members receive specialized care
Lifeguard Inc., an independent not-for-profit health plan based in San Jose, CA, has launched a new care management program to identify members at risk for serious illness and actively engage them in their own care.
How does care management differ from disease management? "Disease management is population management," says Jerry Shefren, MD, chief medical director for Lifeguard. "You identify actions to be taken by members with a given disease, but those actions tend to be general to that population. Care management involves identifying specific members with specific problems and tailoring specific interventions for those members." Once potential candidates for the program are identified, they are contacted by a care manager to develop that tailored health action plan.
Proactive management
Why is such a program important to Lifeguard? "I think that care management has always been the promise of managed care," Shefren explains. "Up to now, we have not been able to establish enough focus or obtain enough data to see which direction we should go in, but proactive management of the population we care for has always been the intent of managed care."
In addition, he notes, legislative changes over the last two years "have increasingly made the traditional utilization management model more difficult to implement — for better or worse — and this has helped lifeguard focus its activities more directly on care management."
Lifeguard chose StatusOne Health Systems, a privately held Internet and consulting company, as its partner for the program. "We looked at many care management and disease management modules to identify which, in fact, might have a cultural fit with Lifeguard, as well as expectations of actually being able to deliver," notes Shefren. "StatusOne, although relatively new, has a different model that really focuses on the kinds of things that physicians typically are not able to do — either because of a lack of time or training — which are necessary for a member to optimize their health."
For example, notes Shefren, consider a member who is significantly overweight but well. He recognizes that he should lose weight, and his doctor has advised him to lose weight, but he has never really received the kind of ongoing support, identification of weight loss programs, and daily encouragement he needs. Nor has anyone identified possible barriers to participation. So, the care manager analyzes the situation and helps the patient come up with approved programs, offers encouragement, and provides monitoring services that typically cannot be provided through the traditional medical care model. "And typically, no one compensates a standard provider for doing that," Shefren adds.
A care manager will do more than just create an exercise plan or a food plan — he will proactively monitor the member’s activities. "What you’d like to do is put a member on a weight loss plan and then weigh him each day," Shefren explains. "That kind activity is almost impossible to do in a practice setting. Daily or frequent interaction to focus on an important health habit is what’s necessary to obtain a change in behavior."
StatusOne also provides coordination of care. "Most of the members have three to five disease processes going on at the same time, which means multiple doctors, multiple drugs, multiple facilities, often with inadequate coordination," Shefren notes. "And again, practitioners are not compensated to provide such coordination. That’s where the health plan does have an incentive, as well as the information and the options to actually accomplish that coordination."
Identifying the candidates
Potential candidates are identified by taking "a rolling 12 months" of Lifeguard medical claims data and looking for patterns of diagnosis and treatment, including pharmacy information, that can predict health care needs over the next 12 months. "That data is looked at monthly, because there’s a 10%-15% turnover in members identified as candidates," Shefren explains. "Typically, between a half of a percent and 1% of any given population would dramatically benefit from a care management program."
Algorithms developed by StatusOne seek to identify specific diseases, medical treatments, failure to take medications as prescribed, or surgical complications.
Once specific members are identified, each is assigned to a care manager. Approximately 90% of those managers who work for Status One are nurses and generally experienced in care management. The care manager then does a further assessment of current status by sending out a questionnaire, and obtains the necessary medical data from Lifeguard and/or the physician.
Of particular importance is identifying barriers. "For instance, some of the more major problems may be compliance problems," notes Shefren. "A patient is supposed to see his doctor once a month, but he has no way of getting there." There are also many resources in the community that are not known by the member or his family that could directly impact on the member’s well-being. StausOne helps Lifeguard identify those resources that are closest to where the members live.
The program information is compiled and stored on a secure Web site by StatusOne. This allows the care manager and Lifeguard to monitor activity and progress. "We monitor the overall success of the program by continually tracking admits per 1,000 and health claims data per 1,000," Shefren explains. "Our ultimate success will be demonstrated through our ability to keep members healthy and out of the hospital."
This care management program, with some components that could be described as preventive health, may go against the current grain in managed health care. Does that concern Shefren? "The term preventive health could be applied to people who are ill, but who could become more ill if certain measures are not taken," he asserts. "Do we have strong enough interventions to actually effect the value equation? Traditionally, they have not been strong enough — or at least the data has not been convincing enough. Perhaps because of the mobility of membership, a member may no longer be your member when his health has improved. Lifeguard has basically made the determination that we have to get into this to know for sure. I would say that most physicians would agree that people with certain problems will have a better or worse outcome depending on treatment and encouragement. It’s not that farfetched; it’s really a matter of how you deliver the intervention. We think this program has significant probabilities of success."
[For more information, contact: Jerry Shefren, Lifeguard Inc. Telephone: (408) 432-3606. Web site: www.lifeguard.com.]
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