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 Marlen.Rodriguez@avmed.org.