Case Management Evolves

AHIP Coverage (May/June 2004)

PULL QUOTE: “The medical model of case management began in the late 1970s, but it wasn't until the late '80s that case management took a holistic approach and used preventive measures to manage cases.”

Case management was once a simple administrative matter ? an insurance adjuster managing a workers' compensation claim.

Today, case managers with nursing, social work, or vocational rehabilitation backgrounds work directly with physicians, hospitals, home health agencies, nursing homes, and other organizations. Case managers now coordinate the health care needs of patients with chronic conditions like asthma or diabetes and patients with catastrophic medical problems such as cancer or severe burns.

“I remember walking into physicians' offices (in 1989) and introducing myself as a case manager, recalls Karen Chambers, past president of the Case Management Society of America (CMSA) in Little Rock, Ark. “They asked, 'What is that?' Now they ask, 'Where is my case manager?' We have come a long way,” she says.

A Long History

Basic management of medical cases has been practiced since the early 1900s when public health nurses and social workers coordinated services through the government or community health sector.

Following World War II, the U.S. government employed a variety of practitioners, including nurses and vocational and rehabilitation counselors, to assist soldiers who had suffered complex injuries. Insurance companies later adopted the approach and began employing a wider range of “case managers” to assist with coordinating services.

“Thirty years ago case managers had all types of backgrounds: degrees in education, vocational rehabilitation, utilization review, and claims adjusting,” Chambers says. “Someone with a high school education could call herself a case manager. They were all trying to manage medical cases.”

In the 1970s, case management began to evolve as a formalized and distinct profession. Demonstration projects funded by Medicare and Medicaid helped prove its effectiveness.

“The medical model of case management began in the late 1970s, but it wasn't until the late '80s that case management took a holistic approach and used preventive measures to manage cases,” Chambers says. In 1995 the CMSA developed its first set of practice guidelines to define and describe the general process of case management. Then, in 2002, CMSA revised “Standards of Practice for Case Management” to put the patient in the center of the case management system.

The CMSA defines case management as “a collaborative process designed to assess, plan, implement, coordinate, monitor, and evaluate options to meet each individual's health needs and to promote successful and cost-effective outcomes.” With the introduction of disease management, evidence-based medicine, and predictive claims modeling and forecasting software over the past several years, case management's definition, process, scope, and responsibilities have continued to evolve, says Kathleen Ward Douglas, principal with K.A. Shannon Consulting in Phoenix.

“The case manager today has more sophisticated tools than ever before to take care of … patients with chronic diseases,” Douglas says.

Until the 1980s, most case managers were generalists. Now, case managers specialize in a variety of fields - oncology, cardiology, gastroenterology, neurology, pulmonology, endocrinology, infectious disease, physical medicine and rehabilitation, pediatrics, gerontology, and psychiatry.

Asthma Management

“In the 1980s, case managers working for insurance companies began to address specific diseases and catastrophic cases,” says Douglas. “The focus was on the catastrophic case, the large dollar claim, and people were struggling with how to coordinate the services for the individual patient.”

In the late 1980s, insurance companies, health care facilities, managed care organizations, and pharmacy management companies discovered the real value of case management as a way to improve the quality of care, and started to incorporate it into their disease management programs, says Vincent Pearson, MD, senior medical director with Independence Blue Cross in Philadelphia.

In doing so, companies found that a patient-centered approach to chronic conditions also helped the bottom line.

“We had been focusing on catastrophic cases, but in the late 1980s the shift changed to chronic illnesses,” Pearson says. “Asthma was one of the first chronic conditions where you could see an immediate improvement in the quality of care, as well as a return on the investment. We found asthma case management could significantly improve member satisfaction.”

For example, an asthma case management specialist with expertise in pulmonology often works with patients and their families to provide education, encourage adherence to recommended treatment, and coordinate care in an effort to alleviate patient suffering and avoid costly hospital and emergency room visits, Chambers says.

“Through utilization management in the 1980s we began to realize that we had a great many patients in the hospital for asthma and diabetes. We saw that what we needed was more intensive intervention for the patient,” says Margaret Leonard, vice president of clinical services with Hudson Healthplan, a nonprofit health plan based in Tarrytown, N.Y.

“When we had 30 members in the hospital for asthma problems, it became clear to us the time was right to begin an asthma case management program and get the primary care provider involved,” Leonard says. Hudson launched its asthma case management program in 2001.

One of nine major chronic diseases, asthma is a lung condition caused by inflammation of the lower airways and obstruction of airflow. More than 25 million adults and children have been diagnosed with mild, moderate, or severe asthma, according to the U.S. Agency for Healthcare Research and Quality.

Despite improvements in care practices, including newer asthma medications that were introduced in the early 1990s, managed care organizations began to realize that environmental issues in the home - allergy triggers from animal dander, dust, and mites - were causing continuing problems for patients, Pearson says.

“We needed to help the patient and the doctor plan individual care so that everyone is on the same page,” says Pearson. “Case management became a way to do this.” Independence Blue Cross also began its asthma disease management program in 2001.

As in most disease management systems, Independence's “care managers” implement asthma care plans based on patients' severity of illness. After patients are identified based on claims information, health risk assessments, and, more recently, predictive modeling software, care managers begin working with patients and their doctors, Pearson says.

“General care management is done telephonically. After their primary care physician identifies them as a likely candidate, patients get letters telling them they have been enrolled. Then they get asthma information on triggers and medications and telephone calls based on their condition,” Pearson says.

Some patients may warrant a home visit to review possible asthma triggers or to receive training on how to use a peak flow meter, which is a hand-held device used to measure the user's ability to expel air from the lungs, he says.

“The focus of case management varies depending on the type of the organization providing services (insurer, health plan, hospital, and disease or case management firm), the types of patients (children, adult, or elderly), and the specialty of the case manager,” says Douglas.

Outcomes

Studies have shown that persons with chronic illnesses like diabetes, asthma, congestive heart failure, hypertension, and other long-term diseases account for only 20 percent of the population but up to 80 percent of total health care expenditures.

“We believe we can lower asthma costs by reducing hospital admissions and ER visits while at the same time improve our members' quality of life,” Leonard says. Affinity's “AIR” program, or Asthma Is Relieved, is directed at about 2,000 members identified with asthma conditions, Younge says. The health plan's 190,000 members include Medicaid, children, and low-income adult populations.

“We started out in 1998 trying to identify high-utilization cases,” he says ? those folks in the ER or admitted to the hospital. We tried to identify those people and (keep them out of the hospital) by home visits, hooking them up with their primary care physicians, and making sure they get the right medicine.”

Over the last year, Affinity's case managers have been identifying members with asthma conditions by using health risk assessments and other survey tools, Younge says.

Asthma case management programs have proven successful at many health insurance companies (see sidebar, p. x). For example, after recently implementing its program, Blue Cross and Blue Shield of North Carolina registered a 64 percent decrease in asthma-related inpatient admissions and a 65 percent reduction in emergency room visits.

CIGNA Pharmacy Management also helped to improve health outcomes of members with asthma. Over a period of a year, members who participated in CIGNA's Asthma Outcomes Improvement Program required 50 percent fewer hospitalizations and emergency room visits while they decreased their need for asthma rescue therapy by 36 percent (See sidebar, p. X)

The Future

Expansion of case management in the 1990s led organizations like the CMSA to develop standards for case managers and other groups to offer certification and accreditation, says Douglas, a former chair of URAC's case management advisory committee.

Certification organizations like the Commission for Case Management Certification, the National Academy of Certified Case Managers, the American Nurses Association, and the American Board of Managed Care Nurses offer certification for case managers in nursing, social work, and vocational fields. Accrediting bodies like the Utilization Review Accreditation Commission and the National Committee for Quality Assurance set standards for disease and case management companies.

“These steps helped to bring case management to the forefront of health care,” Douglas says.

During the past four years, case managers have become more proactive, using specialized software and other screening tools like health risk assessments to predict and identify potential high cost, high resource-intensive patients, Chambers says. These patients are matched with case managers to receive educational material or direct health care or preventive services.

With the proliferation of case and disease management, one of the challenges for providers is to coordinate case managers who may be assigned to the same patient, Pearson says. “If we find out there is a hospital case manager, we try to contact him or her and coordinate services,” Pearson says. “Generally physician groups don't have case managers unless they are in a delegated group,” which is paid to provide certain services, such as disease management. “We have to make sure there isn't duplication in delivery of case management services,” Pearson says.

Douglas agrees. “We don't want to confuse the consumer of health care with a number of case managers calling,” she says. “The patient desperately needs one case manager to coordinate everything and be an advocate.”

Still, the competition among disease management and case management companies - each with their own case managers ? is driving quality higher, Douglas says. “Employers are challenging insurers and disease/case management companies to do a better job and achieve clinical outcomes,” she says. “Consultants are working with large employers to monitor results. Employers are saying, 'If you can't do the job we will find somebody who can.'”

That somebody is the right case manager.

Jay Greene is a freelance health care writer based in St. Paul, Minn.

SIDEBAR 1.

Success in Asthma Case Management

The use of asthma case management by health insurers, health plans, and disease management companies has exploded in the last few years. Data is just starting to show how successful case management programs are at lowering health care costs and improving the quality of life for patients with asthma conditions.

UPMC Health Plan in Pittsburgh began its asthma management program in 2000. From January 2003 to September 2003 hospital admissions for asthma patients in the program decreased 12 percent and emergency room visits declined 36 percent, saving a total of $181,192 on admissions and ER visits, the company says.

A year into “BluePrint for Health,” an initiative managed by American Healthways, a Nashville-based disease management company, members of Blue Cross Blue Shield of Minnesota experienced a 9 percent decrease in ER visits per 1,000, a 5 percent decrease in hospital admissions per 1,000, and a 12 percent decrease in total per member per month costs for patients with asthma.

AvMed Health Plans, a Miami-based health benefits company, says it uses a variety of educational and home visits with its “EZ Breath'n” asthma management program to reduce hospital and emergency department visits.

Fallon Community Health Plan, Worcester, Mass., saves about $1,000 per member per year by using its asthma management program, officials say.

At Blue Cross and Blue Shield of North Carolina, case management intervention resulted in a 15 percent increase in asthma patients taking control medications and a 34 percent increase in the percentage of members reporting that they use a peak-flow meter to monitor their asthma.

Health Alliance Plan in Detroit is using the “Taking on Asthma” program to help children, their families, and school officials understand how to control asthma and prevent problems through improved medication management and reduced environmental risk factors. HAP expects to decrease asthma-related emergency room visits, hospitalizations, and missed school days and to improve asthma medication management. In a previous review of HAP's adult asthma management program, asthma ER visits declined 43 percent and hospital stays declined 24 percent.

M-CARE, a nonprofit health plan owned by the University of Michigan, has been able to reduce its ER visits for asthma attacks to 45.85 per 1,000 members compared with the national average of 68.67 per 1,000, officials say.

- J.G.

SIDEBAR 2

“Taking on Asthma” Initiative Gets a Boost From the EPA

An initiative designed to encourage health insurance plans and provider networks to enhance asthma management programs has received another funding and recognition boost by the U.S. Environmental Protection Agency.

The initiative - “Taking on Asthma: Communication, Education and Outreach” - is sponsored by America's Health Insurance Plans (AHIP) and is supported through a cooperative agreement with the EPA. After AHIP completed its initial one-year agreement in September 2003, and was awarded an additional three-year agreement through 2006.

Launched in 2001, “Taking on Asthma” is a national program to improve the quality of care provided to people with asthma and to enhance their quality of life (For more information, visit www.takingonasthma.org ).

The initiative is based on the premise that health plans and insurers have a unique opportunity to offer evidence-based asthma programs that include the management of environmental asthma triggers, including irritants such as second-hand smoke and major indoor allergens such as dust mites, cockroaches, pet dander, and mold.

According to Caroline Erceg, AHIP's deputy director of chronic care initiatives, the objectives of “Taking on Asthma” include:

• Assessing the efforts of health insurance plans to develop tracking and monitoring mechanisms to reduce the number of missed work and school days and the number of emergency room visits and hospitalizations due to asthma
• Identifying and promoting best practices for improving health outcomes in asthma care management
• Increasing the integration of environmental management in comprehensive asthma care management
• Identifying and disseminating the most effective asthma management tools designed for health plans and insurers, providers, and patients.

Under the EPA grant, AHIP will assess asthma programs offered by health plans and insurers and identify gaps in the environmental component of the programs. AHIP also will disseminate culturally and linguistically appropriate educational tools, resources, and model health plan practices to assist with integrating environmental management into asthma programs, Erceg says.

With the EPA grant in 2003, AHIP recognized San Francisco-based Blue Shield of California's “Reaching Your Peak” asthma program with an exemplary practice award.

Blue Shield's self-management program offers educational material, a peak flow meter, and telephonic registered nurse support to high-risk patients. Practitioners also receive progress notes about their enrolled patients at 6, 12, and 24 months (based on patient surveys).

After 12 months, emergency room visits for Blue Shield of California's asthma patients declined by 47 percent. The health plan also exceeded the program's annual goal of 80 percent for patient satisfaction.. Patients who have completed case management in the Reach Your Peak program show a positive return on investment, reflecting a $3.80 per member per month savings at three years, the company says.

With last year's EPA grant, AHIP also recognized Health Alliance Plan in Detroit. HAP's “Airwaves” asthma management program aims at increasing the knowledge levels of children affected with asthma and promoting behavior change and accountability of parents and teachers to reduce environmental asthma triggers in households and in the schools. (See sidebar, p. x).

AHIP collaborated with the Academy of Allergy, Asthma, and Immunology (AAAAI) to develop a free online continuing education program, “The Environmental Management of Asthma.” The program's objective is to equip the medical community and health insurance plans with resources to incorporate environmental management into asthma disease management programs and clinical practices. For more information, visit www.aaaai.org .

In addition, the “Taking on Asthma Resource Guide” helps promote best practices and key features of member health plans and offers guidance on developing and implementing effective asthma management programs. The guide is available in hard copy and also online at www.takingonasthma.org .

-J.G.