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Collaborative effort helps chronically ill
Program targets members with psycho-social issues
An approach that incorporates its telephonic integrated health coaching services with health plan case management and other health management programs, community-based resources, and physician practices has paid off for Health Integrated.
The Tampa, FL-based targeted population health management company contracts with health plans to help manage the care of chronically ill members who also struggle with psychological issues and face social challenges.
"Left alone, these psychosocial challenges can undermine the best efforts of physicians, family members, and even patients in managing chronic diseases. We work with the 10% to 15% of a health plan's chronically ill population that represents as much as 50% of the cost of care," says Mike Miniati, vice president for marketing.
Health Integrated's Synergy Targeted Population Health Management program provides health coaching, education, and support for chronically ill individuals through contracts with health plans. Care coaches, most of whom have a behavioral health background, work telephonically with members to help them manage their chronic illnesses and psychosocial barriers.
They collaborate with the company's community-based outreach coordinators if the member needs transportation to the doctor's office, help with housing problems, or other community resources.
Having outreach coordinators in the community helps Health Integrated's care coaches connect with hard-to-reach members.
"We initiate outreach telephone calls and mailers to engage the members so the care coaches can work with them over the phone on preventive care. Then we work together as a team with the coaches and physician practices to find a solution to problems and to empower these members to work on improving their health," says Dania Anderson, LCSW, Health Integrated outreach coordinator who works with members of a New York City-based Medicaid managed care plan.
The outreach coordinators and the health coaches work closely with the health plan's case management and other care management programs as well, Miniati says.
"We share what we do with the health plan and they share what they do. We work together to get help for the members so they can be healthier and stay out of the hospital," he says.
The program includes Care Coordination Grand Rounds during which Health Integrated's staff and the health plan's clinical leadership review the challenging cases and brainstorm ways to ensure that appropriate care is being delivered smoothly.
"We work together on the challenging cases and figure out the best way to manage them," he says.
Health Integrated takes the health plan's claims and other data and uses its proprietary predictive modeling tools to identify the highest-risk members who are eligible for the program.
"We also work with health plans to identify groups that may not fit into a particular algorithm but still might be challenging for the health plan to manage," Miniati adds.
For instance, one client requested that Health Integrated work with its Supplemental Security Income (SSI) patients whether or not they met the predictive modeling criteria.
When members are identified for the program, they receive an automated voice message telling them they will receive a mailing about a new program offered by their health plan.
After the mailing has been delivered, they receive an outreach call from engagement specialists who are trained to engage the members and educate them about the program.
"We don't talk about specific conditions. We talk about how we can help them work with their health care providers to feel better. We invite every member to work with a Synergy clinician, but we also offer them the option of participating in other ways," he says.
For instance, some members choose to receive help in managing their care through an e-mail or an interactive voice response system, mailings, or a combination of both.
If people are not reached or don't agree to participate in the beginning, Health Integrated reaches out to them on a regular basis to remind them of the program and their option to work with a health coach to improve their quality of life.
"When people don't engage in the beginning, we don't give up on them. We regularly ensure they know that the program is open to them. The whole idea is to stay in touch with the members until the point in time when they want to actively participate in the program and possibly engage with clinicians," he says.
When members agree to participate in the program, they are assigned a care coach who may be a licensed social worker, a psychiatric nurse, a licensed mental health counselor, a family therapist, or a registered nurse.
"We lean more toward the behavioral sciences because many members with exacerbated chronic illnesses also have psycho-social issues that have not been addressed. We identify and overcome the psycho-social barriers before we start working on the chronic issues," Miniati says.
The care coaches work with the members to establish long-term goals and start by working on short-term goals that will help them meet their long-term goals.
"We don't tie the goals directly to a condition, but look at long-range goals, like being able to go to a grandson's baseball game without getting tired out or feeling uncomfortable. A short-term goal might be something like walking a half block as a starting point," he says.
The care coaches also empower the members to better communicate with their physicians.
For instance, the member may not be following through with the treatment plan simply because he or she doesn't understand the doctor's instructions. The care coach works to increase understanding of the treatment plan and to frame questions for the member to address with the physician on the next visit.
Members typically work with the same clinicians for as long as they are in the program.
"By addressing the critical interplay between medical, psychological, and social health and by offering all targeted members with the opportunity to engage with a dedicated care coach, Health Integrated has established a program unlike any in the industry that delivers improved quality of life for members, better clinical outcomes, and lower health care costs," Miniati says.