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Demonstration project improves outcomes for ill
CMs work with patients by telephone and face to face
A Medicare demonstration project in Florida that includes both telephonic case management and face-to-face interventions has improved clinical outcomes for beneficiaries who are eligible for both Medicare and Medicaid and have congestive heart failure or any combination of comorbidities that include congestive heart failure, diabetes, and coronary artery disease.
The program, which started in 2005, has been so successful that the Centers for Medicare & Medicaid Services (CMS) has extended its contract with LifeMasters Supported SelfCare, an Irvine, CA-based provider of health improvement services.
"The program has demonstrated cost-effectiveness to Medicare, and our preliminary analysis indicated that we have improved the clinical outcomes for a very difficult-to-manage population," says Christobel Selecky, CEO of LifeMasters.
The goal of the program is to reduce preventable utilization with a combination of health coaching and lifestyle changes, Selecky says.
CMS is measuring the outcomes for the group that LifeMasters is managing against a control group.
There are about 28,000 participants in the program.
"We are showing good results in our population compared to the control group and are slightly above break-even for the new cohorts in the program. People who have been in the program since it began in 2005 are getting older and sicker and experience higher health care costs than the new participants," Selecky says.
Participants in the disease management program are followed by nurses in a call center called clinical nurse consultants (CNCs) and/or community-based case managers called community service RNs (CSRNs) who work with the beneficiaries in their homes.
"The team in the field and the team at the call center are extremely tightly integrated and refer back and forth to each other," Selecky says.
Referrals for the program come into the call center where specialists complete an evaluation and determine if the person's care could be coordinated over the telephone or if they need face-to-face care, says Vicki Manning, RN, community services RN team manager.
"It's a seamless system. If the clinical nurse consultant at the call center has concerns about one of the participants, they send a referral to the community service RN or social worker to evaluate the participant in their home," she says.
"LifeMasters' goal is to manage as many people as possible by telephone because successful programs need to be scalable. However, to ensure that all participants are getting the help they need, different options must be provided," Selecky points out.
About 30% of the participants have had a face-to-face visit with a LifeMasters nurse at least once, but only about 94% of them are followed regularly by the clinical nurse consultants in the call center.
"People tend to have the preconceived notion that a telephonic program won't work with older or underserved participants, but it does work if there is an outlet for other interventions when required," Selecky says.
When CMS sends LifeMasters the names of individuals eligible for the program, LifeMasters contacts the beneficiaries and invites them to participate in the program, then sends a letter to their primary care physicians explaining the program. The participants are assigned a nurse who calls them on a regularly scheduled basis.
"The frequency of contact depends on the severity of the individual's conditions. Many of the participants are not accustomed to focusing on their health, and the nurses may gradually ease them into managing their condition," she says.
Selecky attributes part of the success of the program to a unique method of stratifying participants, a combination of traditional stratification based on utilization and cost of care with the Patient Activation Measure, a tool that assesses an individual's likelihood to engage in making health care changes.
The Patient Activation Measure assesses a person's knowledge, skills, and confidence in playing a role in their own health care and ranks them in one of four activation levels according to their engagement in health care.
"We have researched this method and found that if the nurse tailors the conversation according to what level of activation the person is at, we can make a dramatically different impact," she says.
The nurses use the results of the Patient Activation Measure and the participant's level of severity to gear their encounters, using motivational interviewing techniques.