- Email: [email protected]
Population health management and the role of the case manager
tion's health status and demand for health care. By using the methods and concepts of a variety of disciplines
including epidemiology,
preventive and prospective medicine, case management (CM), health promotion and wellness, health education, demand management, and public health
an entire population is assessed for the need for intensive health
intervention, candidates are identified, and technology is combined with personal intervention to carry it out. TCM
60
N. . . .
ber/D. . . . bet 1999
For better or worse, no commonly accepted definition exists, which leaves significant flexibility to adapt PHM to fit the needs of your organization and your population(s). For the purposes of this article, PHM is defined as a field of endeavor that intentionally and proactively uses a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (ie, the illness and injury burden), health status, and health care utilization of defined populations. This definition is useful because it simultaneously provides a general framework for the field and narrows the focus of concern yet maintains considerable flexibility to adapt CM, health promotion, preventive medicine, and demand management methods to the needs of very different populations. CM professionals likely will play a central role in the evolution and direction of this endeavor.
Alcohol and drug abuse
Low back pain and injuries
Arthritis
Mental distress and depression
Asthma
Minor self-limiting medica! conditions
Cardiovascular risks
Overuse and misuse of emergency departments, health services
Chronic diseases Cumulative trauma disorders High-risk pregnancy
Passive consumer behavior Prescription Complications or inappropriate use Recreational or sports injuries
HIV/AIDS Home accidents Inadequate consumer cost-sharing Inappropriate provider choice/type, care site Inappropriate complementary medicine use
Sexually transmitted diseases Smoking-related illnesses Somatic complaints (ie, stress problems) Vehicular injuries Work-related injuries
What Makes PHM Different? Eight key characteristics distinguish PHM from its associated fields and disciplines. Essentially, PHM: 9 Requires a defined population. This prerequisite means you must be able to identify each individual in the population and be able reach him or her by mail and telephone at a minimum; E-mail addresses would be very helpful, also. 9 Requires a health risk appraisal (HRA) or health survey on a regular basis as the primary data collection tool. These questionnaire instruments provide information on health behaviors, health risks, readiness to change, social support, preventive screening performed, recent symptomatology, use of medical self-care texts and the Internet, and other selected issues. This information is maintained in a database for inter~ vention and targeting. 9 Uses an explicit set of criteria to prioritize interventions as to which individuals require follow-up. Criteria may include health status effects, sick leave/absenteeism effects, productivity, or health care utilization and cost. These criteria help set priorities for proactive intervention with individuals who have completed the HRA and
Intervention
Description
IP
Individual patient
Assess individual patients in health care settings
GRP
Group programs
Conduct group education sessions in health care settings
REF
Refer patients
Refer patients to outside organizations
PM
Printed materials
Provide printed materials
VM
Video materials
Provide video materials
AM
Audiotape materials
Provide audiotape materials
SDC
Serf-directed change materials
Provide seif-direcr Change materials with or without formal incentives
SG
Support group
Provide sup,port group opportunities
LT
Laboratory test
Order laboratory tests
FAX
Fax information
Send health information by fax
WS
Worksite group education
Provide worksite-based group education sessions
HAL
Health advice line
Give health advice through on-line telephonic support
PC
Personal coaching
Coach.or mentor patients
NL
Newsletter
Publish periodic newsletter
HC
Home care
Provide home care with education
HRA
Health risk appraisal
Perform health risk appraisal
WEB
Intemet
Recommend health care website
FI
Formal incentives
Provide a formal incentive
CE
Community event
Host a community event
PD
Prescription drug
Prescribe medication or neutraceutical
N.... b~/D~r162 199~
TCM 61
are part of the information database. 9 Has a proactive orientation. Instead of waiting for individuals to seek preventive services, mail, telephone, or Email contact is initiated independently of individual action or requests. This proactive approach supports change related to the criteria used and the potential health issues identified through the HRA. Table 1 lists the most common health or prevention targets associated with working populations. 9 Uses many types of intervention modes. PHM uses various methods to address the types of issues identified in Table 1. Table 2 contains a partial list of common intervention modes. 9 Is based on personalized intervention strategies. For example, instead of providing all clients with similar written materials, their reports are based on a large number of personal variables, including age, gender, risk behavior, learning style, readiness to change, computer access, and other parameters. This high degree of personalization is made possible by computerization and advanced media production capability.
ventive intervention. CM's role and function are strengthened considerably when good longitudinal data are collected and used to prioritize and evaluate intervention services. Key r d A PHM approach uses eight key elements to manage the health of individuals in a defined population.
Regular Health Survey or HRA One of the most important aspects for proactive health management programming is a health survey that is used every 6 to 12 months. These surveys should fulfill a wide range of functions, including identifying at-risk individuals, monitoring health risk prevalence in the population, providing proxy measurement variables for economic extrapolation, determining the stage of readiness for key health behaviors, identifying primary care physicians, prioritizing prevention and screening efforts, determining life satisfaction and social support, ascertaining the use of support materials, and providing information that can be fed back to individuals about their composite health status.
9 Uses a longitudinal perspective. PHM, by its nature, is intended to be used over an individual's lifetime, length of enrollment in a health plan, employment at a particular firm, or other extended period. This approach builds a longitudinal database on an individual's health and preventionoriented behavior and helps ensure greater continuity in intervention than usually can be experienced in today's managed care marketplace. This longitudinal perspective also creates a significant opportunity for continuing research in prevention.
Personalized Report The personal report that results from processing the health survey also is an important part of the core PHM process. The report should look professional, be credible, and reflect a number of modifiers for each person. The more educated the individual, the more references and authoritative sources should be included. As technology becomes more sophisticated, reports should have between 100 and 400 triggers that personalize them for each respondent. The report also should have composite scales that show previous scores by date and should plot out trends in the individual's wellness.
9 Uses epidemiology methods for planning and evaluation that focus on prevalence, incidence, frequency, and severity along with case rates, relative risk and the ability to study changes in disease and condition outcomes. The use of an epidemiological perspective is key to fact-based planning decisions and valid evaluation of disease and condition changes with pre-
Case Management Intervention for Patients with Elevated Risks A key byproduct of the health survey processing is identification of individuals who can benefit from a follow-up phone or mail contact concerning one or more health risks or issues. The more advanced health survey instruments can identify 45 to 85 at-risk conditions of respondents depending on how they
TCM 62
N.... b~ID~mb~,1999
answer health survey questions. The sponsoring employer or managed care plan for the PHM effort can determine how proactive it wants to be in addressing the at-risk conditions uncovered through the health survey. The interventions can be divided into high- and medium-risk levels; mail-based materials can be used with individuals in the latter group and telephonic contact with the former. This juncture is a primary opportunity for case managers to make a significant contribution to this proactive health management process. Once the individual is contacted by the case manager, his or her willingness to be helped or coached is ascertained, and a plan is established for future follow-up.
Stage-Sensitive Informational Materials Self-directed change and carefully prepared health communication materials are the major areas of this PHM aspect. Based on information provided in the health survey, this material is offered to individuals in their personalized reports and during any at-risk follow-up contact. The change materials outline an 8- to 24week self-guided or self-administered process. These 20- to 40-page handbooks can provide key information and help individuals make gradual changes, deal with their stage of change and level of commitment to specific changes, plan for relapse prevention, examine thought/life dimensions to the change, and provide an opportunity for recordkeeping and personal feedback. These materials also can be connected with formal incentives when appropriate. Medical Self-Care References in the Home Medical self-care reference texts have been used widely since the early 18th century, first in Europe and then in the United States. Within the past 20 years, these "doctor's handbooks" have been upgraded into more clearly articulated guidelines to help users make the most appropriate decisions regarding their symptom(s). Now these books have been written for such population subgroups as seniors, young children, infants, Hispanic and other ethnic and language groups, people with low read-
CMs need to understand the technology sufficiently to help shape its application and use in PHM programs. CMs need to acquire greater knowledge about the various clinical conditions and prevention aspects that are the focus of, PHM. CMs need to shift from a heavilytreatment-oriented perspective for difficult diseases or conditions to more of a lifestyle perspective that emphasizes a variety of less severe behaviors:and conditions.
health status, quality of life, self-efficacy, and health care utilization. PHM specifically addresses the demand side of the health care equation by adopting the perspective of the consumer/patient and attempting to increase the role of the individual in managing and improving his or her own health and well-being. Case managers can have an important and lasting role in shaping and guiding PHM in the years ahead, rn
CMs need to look for opportunities to integrate Drevantiveconcerns into all case management.
CMs need to master behavioral intervention techniques more fully, particularly stage of readiness ,applications. CMs need to increase participant empowerment and self-efficacy, helping clients operate with greater personal responsibility for their own health and well-being. CMs need to acquire skills that will help them broaden participants' interest from purely medical issues of health to much broader paradigms of health and well-being.
ing levels, chronic disease sufferers, and others. The use of a medical self-care reference text as a core PHM element ideally should involve either face-to-face training or an explanatory video on how best to use the book.
The exchange should enhance the callers' self-efficacy about health issues; it also should include questions as to their interest in behavior changes or selfdirected change materials and referral to local community resources.
Monthly Wellness Newsletter
I m p l l a a h n u for Case ~ ~ Many implications for case managers flow from this discussion of CM's potential role in PHM. Some of the major implications are listed in Table 3.
This component, a monthly newsletter sent directly to indi~ciduals' homes, should be 6 to 10 pages that are upbeat, easy to read, useful, information-oriented, stage-sensitive, and interesting. Ideally, the newsletter should highlight the other core PHM components as reinforcement. The newsletter acts in the same way as marketing communications: yields repetitive exposures, encourages receptivity to new ideas, and cultivates ~ew behaviors.
Health Advice Phone Line Staffed by Case Managers This toll-free phone line should be available 24 hours a day, 7 days a week, and provide the full range of information functions. It should be capable of full integration with longitudinal health sur'vey data, specific content of sequential personal reports, case manager notes and contact sequence, requested materials, and status on any applicable incentive program. This access allows the case managers who staff the health advice line to know almost all the important health management issues for individuals calling with health-related issues.
As health care costs continue to increase, pressure likewise will increase to establish and use efficient systems to improve the health of defined populations and contain their health-related costs. PHM methods and approaches are the remedy of choice because they have the potential to efficiently reach those in need and ready for help. Case managers have an opportunity to make significant contributions to this newly emerging field. Additionally, the long-term concerns of PHM will encompass many health. aspects associated with a more expansive approach to prevention. These aspects may include personal and work productivity, quality of life, social support, functional capability, and higher levels of health enhancement. Thus, PHM is concerned with intervening for individuals in families, health plans, institutions, communities, and subpopulations, as well as their health risks,
llibllegmphy Breslow L. From disease prevention to health promotion. JAMA 1999;281:1030-3. Chapman L. Population health management. Art of Health Promotion [newsletter] 1999;3(2):1-12. Chapman L. Health management: optimal approaches for managing the health of defined populations. Indianapolis: Summex Corporation; 1997. p. 175. Chapman L. Integrated prevention: applications for managed care settings. Indianapolis: Summex Corporation; 1996. p. 134. Fries J, et al. Reducing health care costs by reducing the need and demand for medical services. N Engl J Med 1993;329:321-5. Prochaska J, Velicer W. Introduction: the transtheoretical model. Am J Health Promotion 1997;12(1):6-7. Larry S. Chapman, MPH, is a health management consultant who serves as chairman and senior consultant for the Summex Corporation, an Indianapolis; Ind.-based population health management services company. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr.; St. Louis, MO 63146-3318; phone (314) 4153-4350;reprint no. 68/1/103390
N . . . . her/December 1999
TCM
63
including epidemiology,
preventive and prospective medicine, case management (CM), health promotion and wellness, health education, demand management, and public health
an entire population is assessed for the need for intensive health
intervention, candidates are identified, and technology is combined with personal intervention to carry it out. TCM
60
N. . . .
ber/D. . . . bet 1999
For better or worse, no commonly accepted definition exists, which leaves significant flexibility to adapt PHM to fit the needs of your organization and your population(s). For the purposes of this article, PHM is defined as a field of endeavor that intentionally and proactively uses a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (ie, the illness and injury burden), health status, and health care utilization of defined populations. This definition is useful because it simultaneously provides a general framework for the field and narrows the focus of concern yet maintains considerable flexibility to adapt CM, health promotion, preventive medicine, and demand management methods to the needs of very different populations. CM professionals likely will play a central role in the evolution and direction of this endeavor.
Alcohol and drug abuse
Low back pain and injuries
Arthritis
Mental distress and depression
Asthma
Minor self-limiting medica! conditions
Cardiovascular risks
Overuse and misuse of emergency departments, health services
Chronic diseases Cumulative trauma disorders High-risk pregnancy
Passive consumer behavior Prescription Complications or inappropriate use Recreational or sports injuries
HIV/AIDS Home accidents Inadequate consumer cost-sharing Inappropriate provider choice/type, care site Inappropriate complementary medicine use
Sexually transmitted diseases Smoking-related illnesses Somatic complaints (ie, stress problems) Vehicular injuries Work-related injuries
What Makes PHM Different? Eight key characteristics distinguish PHM from its associated fields and disciplines. Essentially, PHM: 9 Requires a defined population. This prerequisite means you must be able to identify each individual in the population and be able reach him or her by mail and telephone at a minimum; E-mail addresses would be very helpful, also. 9 Requires a health risk appraisal (HRA) or health survey on a regular basis as the primary data collection tool. These questionnaire instruments provide information on health behaviors, health risks, readiness to change, social support, preventive screening performed, recent symptomatology, use of medical self-care texts and the Internet, and other selected issues. This information is maintained in a database for inter~ vention and targeting. 9 Uses an explicit set of criteria to prioritize interventions as to which individuals require follow-up. Criteria may include health status effects, sick leave/absenteeism effects, productivity, or health care utilization and cost. These criteria help set priorities for proactive intervention with individuals who have completed the HRA and
Intervention
Description
IP
Individual patient
Assess individual patients in health care settings
GRP
Group programs
Conduct group education sessions in health care settings
REF
Refer patients
Refer patients to outside organizations
PM
Printed materials
Provide printed materials
VM
Video materials
Provide video materials
AM
Audiotape materials
Provide audiotape materials
SDC
Serf-directed change materials
Provide seif-direcr Change materials with or without formal incentives
SG
Support group
Provide sup,port group opportunities
LT
Laboratory test
Order laboratory tests
FAX
Fax information
Send health information by fax
WS
Worksite group education
Provide worksite-based group education sessions
HAL
Health advice line
Give health advice through on-line telephonic support
PC
Personal coaching
Coach.or mentor patients
NL
Newsletter
Publish periodic newsletter
HC
Home care
Provide home care with education
HRA
Health risk appraisal
Perform health risk appraisal
WEB
Intemet
Recommend health care website
FI
Formal incentives
Provide a formal incentive
CE
Community event
Host a community event
PD
Prescription drug
Prescribe medication or neutraceutical
N.... b~/D~r162 199~
TCM 61
are part of the information database. 9 Has a proactive orientation. Instead of waiting for individuals to seek preventive services, mail, telephone, or Email contact is initiated independently of individual action or requests. This proactive approach supports change related to the criteria used and the potential health issues identified through the HRA. Table 1 lists the most common health or prevention targets associated with working populations. 9 Uses many types of intervention modes. PHM uses various methods to address the types of issues identified in Table 1. Table 2 contains a partial list of common intervention modes. 9 Is based on personalized intervention strategies. For example, instead of providing all clients with similar written materials, their reports are based on a large number of personal variables, including age, gender, risk behavior, learning style, readiness to change, computer access, and other parameters. This high degree of personalization is made possible by computerization and advanced media production capability.
ventive intervention. CM's role and function are strengthened considerably when good longitudinal data are collected and used to prioritize and evaluate intervention services. Key r d A PHM approach uses eight key elements to manage the health of individuals in a defined population.
Regular Health Survey or HRA One of the most important aspects for proactive health management programming is a health survey that is used every 6 to 12 months. These surveys should fulfill a wide range of functions, including identifying at-risk individuals, monitoring health risk prevalence in the population, providing proxy measurement variables for economic extrapolation, determining the stage of readiness for key health behaviors, identifying primary care physicians, prioritizing prevention and screening efforts, determining life satisfaction and social support, ascertaining the use of support materials, and providing information that can be fed back to individuals about their composite health status.
9 Uses a longitudinal perspective. PHM, by its nature, is intended to be used over an individual's lifetime, length of enrollment in a health plan, employment at a particular firm, or other extended period. This approach builds a longitudinal database on an individual's health and preventionoriented behavior and helps ensure greater continuity in intervention than usually can be experienced in today's managed care marketplace. This longitudinal perspective also creates a significant opportunity for continuing research in prevention.
Personalized Report The personal report that results from processing the health survey also is an important part of the core PHM process. The report should look professional, be credible, and reflect a number of modifiers for each person. The more educated the individual, the more references and authoritative sources should be included. As technology becomes more sophisticated, reports should have between 100 and 400 triggers that personalize them for each respondent. The report also should have composite scales that show previous scores by date and should plot out trends in the individual's wellness.
9 Uses epidemiology methods for planning and evaluation that focus on prevalence, incidence, frequency, and severity along with case rates, relative risk and the ability to study changes in disease and condition outcomes. The use of an epidemiological perspective is key to fact-based planning decisions and valid evaluation of disease and condition changes with pre-
Case Management Intervention for Patients with Elevated Risks A key byproduct of the health survey processing is identification of individuals who can benefit from a follow-up phone or mail contact concerning one or more health risks or issues. The more advanced health survey instruments can identify 45 to 85 at-risk conditions of respondents depending on how they
TCM 62
N.... b~ID~mb~,1999
answer health survey questions. The sponsoring employer or managed care plan for the PHM effort can determine how proactive it wants to be in addressing the at-risk conditions uncovered through the health survey. The interventions can be divided into high- and medium-risk levels; mail-based materials can be used with individuals in the latter group and telephonic contact with the former. This juncture is a primary opportunity for case managers to make a significant contribution to this proactive health management process. Once the individual is contacted by the case manager, his or her willingness to be helped or coached is ascertained, and a plan is established for future follow-up.
Stage-Sensitive Informational Materials Self-directed change and carefully prepared health communication materials are the major areas of this PHM aspect. Based on information provided in the health survey, this material is offered to individuals in their personalized reports and during any at-risk follow-up contact. The change materials outline an 8- to 24week self-guided or self-administered process. These 20- to 40-page handbooks can provide key information and help individuals make gradual changes, deal with their stage of change and level of commitment to specific changes, plan for relapse prevention, examine thought/life dimensions to the change, and provide an opportunity for recordkeeping and personal feedback. These materials also can be connected with formal incentives when appropriate. Medical Self-Care References in the Home Medical self-care reference texts have been used widely since the early 18th century, first in Europe and then in the United States. Within the past 20 years, these "doctor's handbooks" have been upgraded into more clearly articulated guidelines to help users make the most appropriate decisions regarding their symptom(s). Now these books have been written for such population subgroups as seniors, young children, infants, Hispanic and other ethnic and language groups, people with low read-
CMs need to understand the technology sufficiently to help shape its application and use in PHM programs. CMs need to acquire greater knowledge about the various clinical conditions and prevention aspects that are the focus of, PHM. CMs need to shift from a heavilytreatment-oriented perspective for difficult diseases or conditions to more of a lifestyle perspective that emphasizes a variety of less severe behaviors:and conditions.
health status, quality of life, self-efficacy, and health care utilization. PHM specifically addresses the demand side of the health care equation by adopting the perspective of the consumer/patient and attempting to increase the role of the individual in managing and improving his or her own health and well-being. Case managers can have an important and lasting role in shaping and guiding PHM in the years ahead, rn
CMs need to look for opportunities to integrate Drevantiveconcerns into all case management.
CMs need to master behavioral intervention techniques more fully, particularly stage of readiness ,applications. CMs need to increase participant empowerment and self-efficacy, helping clients operate with greater personal responsibility for their own health and well-being. CMs need to acquire skills that will help them broaden participants' interest from purely medical issues of health to much broader paradigms of health and well-being.
ing levels, chronic disease sufferers, and others. The use of a medical self-care reference text as a core PHM element ideally should involve either face-to-face training or an explanatory video on how best to use the book.
The exchange should enhance the callers' self-efficacy about health issues; it also should include questions as to their interest in behavior changes or selfdirected change materials and referral to local community resources.
Monthly Wellness Newsletter
I m p l l a a h n u for Case ~ ~ Many implications for case managers flow from this discussion of CM's potential role in PHM. Some of the major implications are listed in Table 3.
This component, a monthly newsletter sent directly to indi~ciduals' homes, should be 6 to 10 pages that are upbeat, easy to read, useful, information-oriented, stage-sensitive, and interesting. Ideally, the newsletter should highlight the other core PHM components as reinforcement. The newsletter acts in the same way as marketing communications: yields repetitive exposures, encourages receptivity to new ideas, and cultivates ~ew behaviors.
Health Advice Phone Line Staffed by Case Managers This toll-free phone line should be available 24 hours a day, 7 days a week, and provide the full range of information functions. It should be capable of full integration with longitudinal health sur'vey data, specific content of sequential personal reports, case manager notes and contact sequence, requested materials, and status on any applicable incentive program. This access allows the case managers who staff the health advice line to know almost all the important health management issues for individuals calling with health-related issues.
As health care costs continue to increase, pressure likewise will increase to establish and use efficient systems to improve the health of defined populations and contain their health-related costs. PHM methods and approaches are the remedy of choice because they have the potential to efficiently reach those in need and ready for help. Case managers have an opportunity to make significant contributions to this newly emerging field. Additionally, the long-term concerns of PHM will encompass many health. aspects associated with a more expansive approach to prevention. These aspects may include personal and work productivity, quality of life, social support, functional capability, and higher levels of health enhancement. Thus, PHM is concerned with intervening for individuals in families, health plans, institutions, communities, and subpopulations, as well as their health risks,
llibllegmphy Breslow L. From disease prevention to health promotion. JAMA 1999;281:1030-3. Chapman L. Population health management. Art of Health Promotion [newsletter] 1999;3(2):1-12. Chapman L. Health management: optimal approaches for managing the health of defined populations. Indianapolis: Summex Corporation; 1997. p. 175. Chapman L. Integrated prevention: applications for managed care settings. Indianapolis: Summex Corporation; 1996. p. 134. Fries J, et al. Reducing health care costs by reducing the need and demand for medical services. N Engl J Med 1993;329:321-5. Prochaska J, Velicer W. Introduction: the transtheoretical model. Am J Health Promotion 1997;12(1):6-7. Larry S. Chapman, MPH, is a health management consultant who serves as chairman and senior consultant for the Summex Corporation, an Indianapolis; Ind.-based population health management services company. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr.; St. Louis, MO 63146-3318; phone (314) 4153-4350;reprint no. 68/1/103390
N . . . . her/December 1999
TCM
63