- 1. From Wellness to Disease Management: Covering the Health
Care Continuum
2. Reality Check The top three causes of death are heart
disease, cancer and stroke; The leading cause of all three is. A.)
High Blood Pressure B.) Fatigue C.) Obesity The director of the
Behavioral Medicine Research Center at Baylor College predicts what
percentage of Americans will be overweight or obese by 2040. A.)
50% B.) 90% C.) 75% What percentage of US adults do not engage in
any leisure time physical activity. A.) 40% B.) 25% C.) 60%
(Department of Health and Human Services) An American Cancer
Society report shows obesity and lack of physical activity causes
how many cancer cases in the United States? A.) 1/5 B.)1/2 C.) 1/3
3. For Every 100 Employees 4. 60 are Sedentary 5. 25 Smoke 6. 64
are Obese/Overweight 7. 27 Have Heart Disease 8. 10 Have Diabetes
9. 50 Have High Cholesterol 10. 24 Have High Blood Pressure 11. 50
Are Distressed or Depressed 12. Reducing one health risk can Reduce
absenteeism by 2% Improve productivity by 9% Reference: Pelletier
B, Boles M, Lynch W. (2004). Change in health risks and work
productivity over time. J Occup Environ Med. Small changes, Big
Impact 13. Activation! Our level of personal activation (Take
Chargedness) determines our behavior, our risks, our likelihood to
change, and our medical costs. Diet Exercise Disease specific
self-management Consumeristic behaviors 14. 70% 46% 35% 21% 15% 12%
10% Depression Stress Blood Sugar Control Overw eight Smoking Blood
Pressure Sedentary Lifestyle Increased health risk, increased cost
Impact of Modifiable Risk Factors on Medical Expenses Adapted from
Goetzel RZ, Anderson DR, Whitmer RW, et al, Journal of Occupational
and Environmental Medicine (40) (10) October 1998, 1-12
Annualadjustedmedicalexpenses ie. Overweight individuals cost 21%
more than those whose weight is in the healthy range 15. Care
Management: Every Day Health CareEnhance Health Coach Special
Beginnings Disease Management Case Management SUPPORT FOR EVERY DAY
HEALTH WELLNESS COACHING SUPPORT MANAGEMENT Integration between
systems, people, programs Lifelong support for members at any
health stage Simplification for member, employer, physician
Transformation of health care system 16. CareEnhance: Decision
Support The difference betweenwondering what to do and knowing. 17.
CareEnhance: Decision Support 24/7 toll-free phone access to
registered nurses 5 call centers and support for more than 100
languages Help knowing when, where (or whether) to seek care
Library of over 1,100 prerecorded health topics Program reminders
mailed to members quarterly Administered by McKesson Health
Solutions . 18. Health Coach: Lifestyle Change The difference
betweeninaction and taking charge. 19. Special Beginnings: Healthy
Pregnancy The difference betweenworry and peace of mind. 20.
Special Beginnings: Healthy Pregnancy Nurses provide one-on-one
member support Assess each members risk to determine education and
outreach Members choice of pregnancy book or DVD (Spanish options)
What to expect during pregnancy and birth Signs of premature labor
and other complications Tailored pregnancy information 24/7 phone
access (CareEnhance after hours) Engine rewards for completing
program 21. Case Management: Advocate, Navigate The difference
between going it alone and having a trusted advisor help you
through. 22. Case Management: Advocate, Navigate Support for
serious illness or injury One-on-one nurse support based on
conditions Nurses advocate, navigate and coordinate care Promote
optimal quality Match resources to needs Avert unnecessary expenses
($20 million in 2005) 1% of members drive 30% of health care costs
Reminder: Case managers can help members understand their
conditions, work with multiple providers and make the most of their
benefits. 23. Disease Management: Change the Future The difference
between an existence controlled by your condition and taking
control of your life. 24. Disease Management: Change the Future
Targets diabetes, cardiac, and respiratory conditions AdviCare
packages may cover additional conditions Prevent or postpone
complications Nurses and clinicians offer one-on-one support
Interventions based on members risk level Newsletters, care
reminders, phone contact, other outreach Support treatment plans
and improve compliance Improved clinical measures and outcomes Help
members understand and manage their condition(s) 25. Disease
Management: Change the Future Disease management is the difference
between... BEFORE Uncontrolled Diabetic with Non-Healing Wound 3
Office Visits $ 375 Hospital Admission $25,000 Surgeon Fees $ 6,000
Prosthetic $12,000 Rehabilitation $24,000 Insulin $ 6,000 TOTAL
$73,375 AFTER Controlled Diabetic 6 Office Visits $ 750 Foot Care
$1,100 Dietician $ 300 Physical Therapy $ 500 Insulin $4,500
Pharmacy Services $ 110 TOTAL $7,260 26. Why Regence Disease
Management Matters 45% of members with chronic conditions do not
receive evidence-based care* Medications, tests and exams, doctor
visits Improve diet and exercise Reduce stress Engaged members make
better health care decisions Improvements in quality of life may
Increase productivity Reduce absenteeism and presenteeism Slow cost
trends over time *Source: McGlynn, et al., New England Journal of
Medicine, 2003. 27. Regence Disease Management Basics Targeted
conditions Diabetes Coronary artery disease (CAD) Congestive heart
failure (CHF) Asthma Chronic obstructive pulmonary disease (COPD)
Depression Anxiety Prevents or postpones complications Supports
treatment plans and improves compliance Helps members understand
and manage their condition 28. Health Care Advocacy for Members 29.
Having A Chronic Illness Is Complicated Only about 20% of people
with health conditions do what they should to maintain good health
Take Medications Do Prescribed Tests Visit Doctor Regularly Reduce
Stress ExerciseFollow Diet 30. Physicians Have Challenges, Too
Health care systems have driven physicians to fix patients, not
maintain their health Lack of time with patients Increasing
prevalence of chronic conditions Shift to short term episodes
rather than long term health status. Our goal is to support the
physician with patient behaviors between office visits 31. We
Stratify the Population Stratification of Risk Rules-based
algorithms Individually stratifies the population so we know where
to start Low Risk High Risk 32. We Apply the Right Level of
Intervention 4 levels of risk stratification Program tailored to
risk level Fluid stratification algorithms (claims, prescriptions,
updates, self report, physician and care calls) Interventions based
on member specific needs and best practice guidelines Level of
intervention is based on individual stratification and risk status
of the member 33. What do members participating in the program
receive? AdviCare participants will be offered: One-on-one
nurse-based counseling Support through telephone calls designed to
help the member through coaching and education Members talk by
phone with a knowledgeable RN who: One-on-one nurse-based
counseling Understands the complexities of their conditions Can
take the time to answer all of their questions Has access to a
variety of educational materials 34. We Address the Whole Person
Its about people, not the disease Understand individual behaviors
and help the participant modify them In order to create change you
must establish unconditional credibility and positive intent Set
goals with the patient that are achievable Build on their successes
All co-morbidities and behaviors must be managed simultaneously by
the same trusted relationship 35. We Extend the Physicians Reach
Expanded interventions between office visits Comprehensive health
condition protocols (evidence based standards of care) Behavioral
modification In market nurses supporting practice patterns with
tools and education A primary goal of our program is to support the
physician with patient behaviors between office visits 36. Outcomes
Reporting Financial semi-annual report reflects pre- versus post
program results Clinical Outcomes semi-annual report on members
overall compliance with selected standards of care Utilization
semi-annual with % change in admissions, length of stay, ER visits
and bed days Member Satisfaction - annually Activity quarterly
report showing members counts and type/frequency of member contact
Note: Client level reporting varies based on group size. 37. Health
Care Cost for Diabetes Population Declined During Years 1 and 2
both in Real Terms and when Compared to Adjusted Base Period Costs
Year 1 Trend is 7% Year 2 Trend is 12% Program Results 38. Diabetes
Clinical Indicator Improvement 39. Results 43,492 Program
participants 677,940 Educational mailings 186,088 Telephonic
interventions Office Visits ALOS (days) ER visits Admissions Bed
Days Utilization Other Professional Pharmacy Outpatient Inpatient
Overall Costs 6.56 6.0 263 157 938 $45 $97 $106 $58 $145 $431
Intervention 6.93 5.2 307 206 1,061 $47 $137 $118 $118 $147 $551 No
Intervention -5% 13% -14% -24% -12% -4% -29% -10% -51% -2% -22% %
Change 40. Member Satisfaction Percent of Members Rating the
Program Good to Excellent Member satisfaction with healthcare
increases steadily so you hear less noise. 0.00% 10.00% 20.00%
30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Used
AdviCare Suggestions & Guidelines Satisfied with Courtesy &
Sensitivity of AdviCare Nurses Overall Satisfaction with AdviCare
78% 89% 78% 41. Success Story Diagnosed with type 2 diabetes for
over a decade. During a Welcome Call, she told the AdviCare nurse
that upon receiving her AdviCare diabetes workbook,she read it from
"cover to cover." She stated more than once how pleased she was
with it; in comparing it with others she had read, she found
AdviCare's to be "more readable" and to contain "better dietary
information" than others she had read. She reported that despite
her long time diagnosis, she looked forward to participating in the
AdviCare program. 42. Making a Difference in Someones Life A member
had a history of substance abuse and uncontrolled diabetes prior to
her calls from the AdviCare program. For four years she had not
been having regular laboratory testing or reviews of her
medications. In 2005, the AdviCare nurses sent her workbooks and
encouraged the member to review the standards of care. The member
also set a goal to call member services and find a physician to
help her manage her diabetes. Since then the member has had her
medications reviewed, her annual exams, and A1C testing. She has
continued to remain sober and stated she attributes her current
health with diabetes to the information and support provided by the
AdviCare nurses. 43. Thank you for attending Jennifer Havlin, BA,
BSN, RN Regence BlueShield (206) 332-5011 [email protected]
