Health care costs have increased significantly in the

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1 A Nurse-Driven, Carve-in Approach for Managing Complex Chronic Conditions Lisa M. Kabasakalian, MHA, MBA, and Richard M. Hassett, MD Introduction Health care costs have increased significantly in the United States in recent years, and a large proportion of these expenses can be attributed to persons with chronic health conditions. In 1995, there were an estimated 99 million Americans with chronic conditions, accounting for $470 billion (1990 dollars) in annual health care spending. Up from $425 billion in 1990, this figure is expected to grow to $503 billion by the year Chronic conditions are the major cause of illness and disability in the United States, accounting for three out of every four deaths [1]. In response to these staggering numbers, disease management has emerged as a strategic method for containing health care costs. This patient-centered, preventive approach to care is still in the innovation phase of its life cycle, and the installation of disease management in health plans has largely been motivated by pressure from the National Commission on Quality Assurance (NCQA). Health plans that have implemented disease management programs to satisfy accreditation requirements, however, have found these programs also can support the mission of improving cost, quality, and member satisfaction. Accordant Health Services, an independent disease management company located in Greensboro, NC, has extended the concept of disease management from top targets such as asthma, congestive heart failure, and diabetes to focus on patients with chronic diseases who historically have been underserved in the health care delivery system. The diseases managed by Accordant (Table 1) are clinically complex, require time-consuming care management, and, in aggregate, have a considerable economic impact. The high cost of treatment, particularly of treating catastrophic episodes, makes these diseases ideal candidates for quality improvement efforts. However, given the relatively low prevalence of these conditions, internal development of disease management strategies is not a viable option for most health care systems. The Accordant Model The Accordant model is a carve-in approach intended to enhance the existing patient-provider relationship. Toward this end, Accordant staff proactively and routinely monitor patient status, educate patients and providers on the prevention of predictable adverse events, and contribute to crisis management activities so that the magnitude of such events is minimized. In the course of providing these services, Accordant employs a variety of proprietary tools resulting from research and development efforts. Initial Research and Disease Profile During the research phase, a team consisting of Accordant s medical director, clinical research and development coordinator, medical advisors, and clinical staff conducts a literature search and collects relevant information on the disease to be addressed. Drawing on evidence-based protocols, standards of care, and position statements from professional societies as well as their own clinical experience, the team creates a profile of the disease that identifies disease prevalence, diagnostics, comorbidities, treatments, and patientmonitoring issues. This profiling activity, along with the cost modeling detailed below, allows Accordant to make a final determination as to whether or not they will be able to impact the cost of treating the disease and/or the quality of life of those patients affected by the disease. If the decision is made to move forward, this phase will support numerous follow-on steps in the model development process and serve as a valuable resource to support ongoing care management activities. Normative Cost Model Accordant constructs detailed baseline cost models that help the team to identify key drivers of cost and support the steps of impact modeling and intervention. The initial data sources for cost include published studies, disease foundations, HCIA (a health care information company based in Baltimore, MD), the National Organization for Rare Disorders, and staff medical advisors. When no data are Lisa M. Kabasakalian, MHA, MBA, Manager, Data and Outcomes, Accordant Health Services, Greensboro, NC; and Richard M. Hassett, MD, Vice President of Medical Affairs, Accordant Health Services. 26 JCOM January 1999 Vol. 6, No. 1

2 OUTCOMES IN PRACTICE available from these sources, average national physician fees provided by Practice Management Information Corporation (a distributor of coding and reimbursement information based in Los Angeles, CA) are applied to utilization estimates to develop baseline cost models. The second-generation models utilize aggregate claims data from Accordant s clients. The final cost model is a detailed breakout consisting of the following main categories: durable medical equipment, medical supplies, ambulance, laboratory, radiology, therapy, physician charges, pharmacy, home health care, facility charges, and other. Impact Model Accordant develops impact models that quantify the anticipated cost and quality benefits to be derived from their key strategies and interventions. Interventions are matched to the key drivers of cost identified in the normative cost model. The second-generation models, now being developed, will apply claims data to quantify actual cost savings. Data Analysis Algorithms Accordant has developed data analysis algorithms that query claims data to identify patients with Accordantmanaged diseases. The algorithms utilize specific sequences and combinations of diagnosis, drug, and procedure codes along with age and gender to accurately identify affected patients. A substantial amount of time during algorithm development is spent identifying and accounting for common claim miscodes. These include: Data entry errors Abbreviation miscodes (eg, is MS mitral stenosis or multiple sclerosis?) Software miscodes. Some software allows coders to choose from an alphabetical pick-list of diagnoses, making it easy to mistakenly select, for example, cystic kidney disease instead of cystic fibrosis. Rule-outs. Physicians code for diseases that are diagnostic possibilities. The code is no longer used once a diagnosis is ruled out. Thus, the ICD-9 code for a disease can appear multiple times in a claims dataset despite the fact that the patient does not actually have the disease. Care Management Action Plan (C-MAP) The C-MAP is a problem-oriented, detailed decision support tool designed to enable comprehensive individual patient care planning. For each diagnosis, the C-MAP describes the presenting signs and symptoms, tests related to the diagnosis, treatment considerations, indicated nursing interventions and education, and goals and desired outcomes of patient management. Identified in the document are the key Table 1. Chronic Diseases Managed by Accordant Disease ICD-9 Code Gaucher s disease Cystic fibrosis , Sickle-cell disease Hemophilia (factor VIII, IX) 286.0, Parkinson s disease 332, Amyotrophic lateral sclerosis Multiple sclerosis 340 Chronic inflammatory demyelinating polyradiculoneuropathy Myasthenia gravis 358, Systemic lupus erythematosus Systemic sclerosis Dermatomyositis Polymyositis Rheumatoid arthritis strategies and methods necessary to generate the anticipated cost and quality benefits of its disease management approach. These key interventions and strategies are embedded in Accordant s patient assessment tools and scripts. Assessment and Intervention Tools Interactive, disease-specific assessment tools have been developed to track the clinical and functional status of patients. These assessment tools evaluate disease severity, risk of predictable complications, the patient s knowledge of their disease, predisposition toward noncompliance, utilization patterns, psychosocial support, treatment complications, absenteeism from work/school due to illness, and awareness of available support groups and national foundations. Customized care management software allows for quick and easy collection of information. Based on patient response, the system prompts Accordant staff to provide scripted patient education or follow-up with the patient s physician. Generic interventions include enhancing access to resources; encouraging participation in local or online support groups; educating about strategies for coping with new deficits; and ensuring compliance with treatment protocols. Disease-specific interventions focus on functional and clinical indicators. For example, patients with multiple sclerosis are educated about the risks, signs, and symptoms of common infections to which they are prone and which require rapid diagnosis and treatment to prevent a functional deterioration related to the febrile illness. The patient is also Vol. 6, No. 1 JCOM January

3 Table 2. Hospital Utilization Trends First Third Enrollment Quarter Quarter 1998 % Change Average length of stay (days) Days per 1000 patients assessed for risk of falling, bladder and bowel impairments, spasticity, fatigue, and a number of other disease-specific concerns. Implementation Patients are monitored by Specialty Services Advisors, onstaff registered nurses with strong clinical backgrounds in complex chronic diseases and case management. The nurses perform comprehensive quarterly assessments and make routine outreach calls to help manage medication regimens and remind patients of preventive measures that will help them achieve their health management goals. From a population perspective, there can be a tendency for patients in remission to ignore early warning signs of progression or exacerbation. Through regular outreach and education, Accordant is able to help patients self-manage their disease, thereby minimizing the potential for predictable adverse complications. Depending on the patient s clinical and functional status and knowledge of their disease, frequency of nurse followup can vary from daily to quarterly. As part of the assessment wrap-up, the nurse summarizes the actions he or she is going to take and encourages the patient to call with any questions or concerns. Nurses are available to answer patient calls 24 hours a day, 7 days a week. This around-theclock support can decrease delays in treatment and reduce unnecessary visits to the emergency department. Although the main strategies of the Accordant program focus on prevention and education, it is understood that complications will occur. In such cases, Accordant s goal is to enhance the management of these events. During crisis situations, Accordant consults with the health plan in the authorization of services and discharge planning for patients, relieving health plans and attending physicians of some of the burden of care. Accordant nurses also assist physicians and patients in coordinating the delivery of services such as durable medical equipment, home health care, physical therapy, occupational therapy, respiratory therapy, and intravenous therapy. Outcomes Measurement Accordant tracks clinical, functional, utilization, process, and Table 3. Quality Indicators Tracked for Selected Conditions Baseline Second Quarter (% of pts) 1998 (% of pts) Systemic lupus erythematosus Lipid screen within past 12 months Patient compliant with surveillance laboratory guidelines Multiple sclerosis (MS) Patient aware of national MS society MS exacerbation reported Impaired bowel control reported Cystic fibrosis Patient (if adult) less than 85% of ideal body weight Patient performs airway clearance technique Patient (if older than 16 years) tested for diabetes within past 12 months patient satisfaction outcomes for all diseases, regularly reviewing all outcomes data to validate and improve the intervention and impact models. Accordant also provides disease-specific and patient-specific quarterly outcome reports to health plans and providers. Satisfaction with the program is high, with 96% of patients rating the Accordant nurse s knowledge of their health care needs as excellent, very good or good (independent survey conducted by Data Management Research, Nashville, TN). Utilization data primarily based on payer report demonstrate reductions of more than 50% in average length of stay and hospital days per 1000 patients after 1 year (Table 2). Table 3 shows recent improvements in patient knowledge and compliance based on self-report during nurse assessment. Lessons Learned Accordant s commitment to continuous quality improvement has enabled the company to quickly overcome initial obstacles while continuously improving key processes. Lessons learned include: How to Show the Value of Disease Management for Less Prevalent Diseases One of the first challenges Accordant faced was convincing health plans to purchase services that affect only a relatively small percentage of their total covered lives. To address this challenge, Accordant performs a Patient Identification and 28 JCOM January 1999 Vol. 6, No. 1

4 OUTCOMES IN PRACTICE Table 4. Example from Accordant s NCQA Crosswalk 1998 NCQA Standard Accordant Service What Accordant Does MCO Benefit QI 6.0 The MCO implements mechanisms to assure member satisfaction. QI 6.1 The MCO assesses member satisfaction by: QI Surveying member satisfaction with the MCO Member satisfaction surveys QI Evaluating member complaints and appeals QI Disenrollment evaluation Accordant complaint/ grievance process Internal surveys quarterly of every Accordant enrollee; external surveys annually through random sample Complaints/grievances reviewed by a quality improvement committee Disenrollment tracked and analyzed Survey results go to client Client complaints/ appeals integrated into MCO process Impact Analysis using a health plan s actual data. Data analyses consistently show that while the total number of patients with Accordant-managed diseases is relatively small, the total number of dollars they account for is large. In addition, Accordant can project a significant return on investment because crisis events frequently associated with these diseases are predictable and can be prevented with appropriate interventions. Together, these two factors have been effective in demonstrating the value of the program to health plans. Another factor that makes the Accordant program attractive to health plans is the relative ease and speed with which it can be implemented and integrated within a health plan s existing administrative and provider infrastructure. Accordant s account service professionals use streamlined process flow documents, Gantt charts, and relevant collateral materials to support the implementation process. Throughout the process, a team of corporate and field-based professionals conduct on-site health plan orientation sessions and provide ongoing customer service. How to Engage Physicians in the Process Accordant is sensitive to the reality that some physicians have developed a considerable amount of skepticism regarding managed care sponsored medical management initiatives. Accordant s contracting strategies do not provide a financial incentive for physicians to participate in the program, so Accordant has had to pursue other avenues to achieve physician buy-in. During the initial program rollout, physicians are sent introductory materials outlining the program s goals and objectives. Additionally, physicians receive a program manual that provides detailed information regarding all aspects of the program. Clinical and project management experts meet with individual physicians requesting additional information. On an ongoing basis physicians receive a variety of reports including patient emergent condition and change of status notifications and, for consultative purposes, have access to Accordant s medical director and a medical advisory board comprising national leaders in each disease. Accordant nurses are available to both support physicians in achieving their care management goals and reduce the administrative burden faced by physicians and their office staffs. To date, these strategies have been successful in building effective working relationships with the physicians treating patients in the Accordant program. How to Help Plans Meet NCQA Requirements Increasing attention is now being paid to quality improvement in health care. Current initiatives such as the President s Advisory Commission on Consumer Protection and Quality in the Health Care Industry [2] have brought national attention to this subject. Created to establish national guidelines for improving health care quality, the advisory commission has widely publicized the need for significant improvement in programs serving chronically ill patients. Accordant helps health plans meet these quality requirements and demonstrate ongoing quality improvement to their external constituencies, such as employer consortiums and NCQA, in several ways. First, Accordant provides a program operations manual to each participating health plan. This manual is useful both as an internal resource for health plan personnel and also as a documentation source to support NCQA accreditation activities. In addition, specific support materials have been designed to help the health plan Vol. 6, No. 1 JCOM January

5 secure NCQA accreditation and minimize the burden associated with the accreditation process. Included in these materials is a crosswalk detailing Accordant s adherence to NCQA guidelines (Table 4). For example, to meet the standard for assessing member satisfaction, Accordant administers health assessment surveys that include scales that measure satisfaction. Average or below-average scores automatically trigger a quality review to evaluate complaints. Conclusion Improving quality along disease-specific lines represents an advance in the continuing evolution of managed care. Chronic disease management is an industry in rapid development, fundamentally reshaping how products are purchased and utilized, redefining health care accountability and profitability. As a result, there is little doubt chronic disease management will continue to foster innovation in the creation of disease management strategies. References 1. The Institute for Health & Aging at the University of California, San Francisco. Chronic care in America: a 21st-century challenge. Princeton (NJ): Robert Wood Johnson Foundation; Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality first: better health care for all Americans. Washington (DC): U.S. Government Printing Office; Copyright 1999 by Turner White Communications Inc., Wayne, PA. All rights reserved. 30 JCOM January 1999 Vol. 6, No. 1