Disease management programs can
help employers improve the health of
their employees, reduce absenteeism due to illness and hospitalizations and save
on premiums costs. While disease management has been a health care industry concept for approximately 10 years, programs
continue to gain momentum with each
passing year as health care costs continue
to rise.
“One of the barriers with disease management in the past has been that employees have not become engaged until they
actually have a problem,” says Marlen
Rodriguez, RN, BSHSA, CCM, director,
Care Management, AvMed Health Plans.
“Today, the trend is to be more proactive in
order to prevent problems from occurring
in the first place.”
Smart Business asked Rodriguez to
explain how disease management programs work.
What areas do a disease management program encompass?
Disease management is a collaborative
process integrating health care resources,
management, finance, and high-quality
service and care delivery. AvMed Health
Plans recently changed its structure to a
‘care management’ approach, providing
four components: disease management
programs, complex case management, catastrophic case management, and specialized care management focused on high-risk conditions.
How does the health plan provider work with
the employer?
The provider may work with a group to
identify its specific needs depending on its
size and demographics. The population is
analyzed to identify its areas of risk. Take
the example of an automotive repair company. The population is generally comprised of males, age 25 to 40, with risk factors such as coronary artery disease and
high blood pressure. Because we know
that, we can help the employer educate its
work force about wellness programs
specifically focused on those areas.
How does the health plan provider assist
employees who need services?
There are dedicated medical directors/advisers who provide support to the
programs. Employees get assigned to care
coordinators who work with and educate
them by phone. These care coordinators
work with the employees’ health care
providers to develop care plans. The frequency of contact depends on the employees’ needs. It may be weekly for a period of
time, then monthly, then quarterly. During
this period, they are receiving information
about their condition, oftentimes in
‘pieces,’ so as not to overwhelm or confuse
them. If the employee has asthma, for
example, he will receive information about
medication, triggers, what he can do to prevent attacks by altering his home environment, etc. In the future, we will also see
more communication via the Web in addition to telephone contact.
What are some of the barriers involved with
reaching out to employees?
Some employees may feel a bit threatened. For example, they may not want
their employer to know they have a certain
condition. Others may not be ready to engage in their health care. We reassure
them by providing information. Others face
time constraints, such as obtaining time off
work to get necessary lab work, etc. We
coordinate care to make it easier for them.
Interventions to assist members are all different, but the main component is ensuring
that they have all the tools they need to
manage their disease. For example, we
make sure diabetics have all the insulin
strips and supplies they need. If the member has asthma, perhaps we arrange for a
respiratory therapist to check his or her
home for environmental triggers. In all
cases, education is the key.
On what areas are the programs focused?
They may include areas such as asthma,
coronary artery disease, diabetes, heart
failure, end-stage renal disease, wounds,
oncology, high-risk maternity, complex
cases of multiple trauma, two or more hospitalizations within 90 days for related
diagnosis (readmissions), AIDS (needing
treatment beyond oral medications), home
health care (i.e., members with complicated, extensive and/or high-cost services),
neonates with complicated medical conditions, ventilator-dependent members at
home, hospice, members leaving facilities
against medical advice (AMA), ER services
(three or more encounters within 12
months) and catastrophic cases.
What does the future hold?
The industry is increasingly using technology to identify members early in their
condition in order to empower members to
make lifestyle changes. We need to start
early and work with employer groups to
create wellness programs focusing on
smoking cessation, weight loss and
increased activity in order to improve the
health of our work force, thus preventing
future chronic conditions. Basic lifestyle
changes will make a major impact going
forward.
MARLEN RODRIGUEZ, RN, BSHSA, CCM, is director, Care
Management, AvMed Health Plans. Reach her at (305) 671-4702
or [email protected].