- Email: [email protected]
Population management outcomes
Guidelines & Outcomes
POPULATION MANAGEMENT OUTCOMES by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
P
opulation management (PM) is an exciting and relatively new practice area for case management (CM). Physician groups are expanding the ambulatory care they provide as the national health care system struggles to identify ways to reduce acute care costs. Beyond the traditional but occasional physician appointment, groups are focusing on nontraditional approaches that cost-effectively meet quality of care standards. CM is assisting by identifying specific populations that would benefit from more frequent contact by the physician groups. This setting is ideal for the involvement of case managers who consistently promote health and wellness along the continuum of care, a primary practice concept. PM began gaining interest in the 1990s and steadily has increased in popularity as the industry continues to identify costeffective modes. PM is best defined as a comprehensive, integrated approach to care and reimbursement based on a disease’s natural progression. The primary goal is to address a specific illness or condition with maximum effectiveness and efficiency regardless of treatment settings or typical reimbursement patterns. This approach emphasizes management of an illness/disease in a manner that focuses both clinical and nonclinical interventions when and where they are likely to have the most positive impact. Ideally, PM prevents exacerbation of a condition and the use of expensive resources, making prevention and proactive CM two important emphases. One organization delivering nontraditional care to identified populations is Hill Physicians Medical Group, a large independent practice association (IPA) in California. Diane Sackl, RN, MSN, clinical educator for the group, says, “About 2 years ago, Hill Physicians began exploring
alternative approaches to traditional physician office visits in an effort to better meet the needs of some of their members with chronic conditions. Through pharmacy and claims data, these members were identified as appropriate candidates for the planned interventions.” The IPA decided to implement group appointment programs in selected physician offices for two populations—members with diabetes and those with migraines. If the pilot programs are successful, the group can use the models to expand to other populations. Outcomes for measurement for both groups include use of the SF-36 before and after the interventions. The diabetes members also undergo HgA1c, weight, and blood pressure readings, whereas the migraineurs complete a specific survey. Baseline values are obtained for all participants, and data are collected immediately after and 1 year after the interventions. To date, five migraine groups and four diabetes groups have been formed. “The concept of the group appointment program is really quite simple,” says Sackl. “The physicians for diabetes, for example, identify members in their practice who have HgA1c values over 8 and who are beginning to present with additional health issues—overweight, high blood pressure, etc. Those with severe comorbidities are not really appropriate for this program because it is geared to a population at high risk for future health problems if they cannot develop better self-care tools right now in their lives. The two most important elements to the success of the interventions are physician participation and continuous reinforcement for self-management behaviors.” For both the migraine and the diabetes programs, the physicians form a partnership with a facilitator experienced in behavioral health to present at each appointment. Nurse experts are used as
guest speakers throughout the series of appointments so members receive up-todate information on all topics related to their condition. The model only slightly resembles a traditional physician appointment or an educational class. Members who completed the diabetes appointment program a year ago continue to show HgA1c values 10% lower overall than their preintervention values. And Sackl notes that blood pressures for all members in this group remain below 140/90, although all had diagnoses of severe hypertension going into the program. SF-36 results show members feeling better about their overall health after completion of the program but, curiously, perceive they are in more pain. Future group SF-36 results, hopefully, will shed more light on this seemingly mixed message. Anecdotally, participating physicians report that their patients who completed the program adhere better to medical regimens. Members who have completed the program report they feel more in control of their condition. A data report related to HEDIS activities planned this spring is hoped to show this population of diabetes patients adhering better to HgA1c laboratory checks quarterly for the past year. PM is an important component to health care choices for patients at high risk for certain conditions. CM has a role in helping improve the outcomes for such groups through implementation of nontraditional activities like the group appointment program. ❑ Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ, is the founder and president of CQI. She can be reached at (619) 226-4141; E-mail [email protected]. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/115957 doi:10.1067/mcm.2001.115957 May/June 2001
TCM 45
POPULATION MANAGEMENT OUTCOMES by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
P
opulation management (PM) is an exciting and relatively new practice area for case management (CM). Physician groups are expanding the ambulatory care they provide as the national health care system struggles to identify ways to reduce acute care costs. Beyond the traditional but occasional physician appointment, groups are focusing on nontraditional approaches that cost-effectively meet quality of care standards. CM is assisting by identifying specific populations that would benefit from more frequent contact by the physician groups. This setting is ideal for the involvement of case managers who consistently promote health and wellness along the continuum of care, a primary practice concept. PM began gaining interest in the 1990s and steadily has increased in popularity as the industry continues to identify costeffective modes. PM is best defined as a comprehensive, integrated approach to care and reimbursement based on a disease’s natural progression. The primary goal is to address a specific illness or condition with maximum effectiveness and efficiency regardless of treatment settings or typical reimbursement patterns. This approach emphasizes management of an illness/disease in a manner that focuses both clinical and nonclinical interventions when and where they are likely to have the most positive impact. Ideally, PM prevents exacerbation of a condition and the use of expensive resources, making prevention and proactive CM two important emphases. One organization delivering nontraditional care to identified populations is Hill Physicians Medical Group, a large independent practice association (IPA) in California. Diane Sackl, RN, MSN, clinical educator for the group, says, “About 2 years ago, Hill Physicians began exploring
alternative approaches to traditional physician office visits in an effort to better meet the needs of some of their members with chronic conditions. Through pharmacy and claims data, these members were identified as appropriate candidates for the planned interventions.” The IPA decided to implement group appointment programs in selected physician offices for two populations—members with diabetes and those with migraines. If the pilot programs are successful, the group can use the models to expand to other populations. Outcomes for measurement for both groups include use of the SF-36 before and after the interventions. The diabetes members also undergo HgA1c, weight, and blood pressure readings, whereas the migraineurs complete a specific survey. Baseline values are obtained for all participants, and data are collected immediately after and 1 year after the interventions. To date, five migraine groups and four diabetes groups have been formed. “The concept of the group appointment program is really quite simple,” says Sackl. “The physicians for diabetes, for example, identify members in their practice who have HgA1c values over 8 and who are beginning to present with additional health issues—overweight, high blood pressure, etc. Those with severe comorbidities are not really appropriate for this program because it is geared to a population at high risk for future health problems if they cannot develop better self-care tools right now in their lives. The two most important elements to the success of the interventions are physician participation and continuous reinforcement for self-management behaviors.” For both the migraine and the diabetes programs, the physicians form a partnership with a facilitator experienced in behavioral health to present at each appointment. Nurse experts are used as
guest speakers throughout the series of appointments so members receive up-todate information on all topics related to their condition. The model only slightly resembles a traditional physician appointment or an educational class. Members who completed the diabetes appointment program a year ago continue to show HgA1c values 10% lower overall than their preintervention values. And Sackl notes that blood pressures for all members in this group remain below 140/90, although all had diagnoses of severe hypertension going into the program. SF-36 results show members feeling better about their overall health after completion of the program but, curiously, perceive they are in more pain. Future group SF-36 results, hopefully, will shed more light on this seemingly mixed message. Anecdotally, participating physicians report that their patients who completed the program adhere better to medical regimens. Members who have completed the program report they feel more in control of their condition. A data report related to HEDIS activities planned this spring is hoped to show this population of diabetes patients adhering better to HgA1c laboratory checks quarterly for the past year. PM is an important component to health care choices for patients at high risk for certain conditions. CM has a role in helping improve the outcomes for such groups through implementation of nontraditional activities like the group appointment program. ❑ Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ, is the founder and president of CQI. She can be reached at (619) 226-4141; E-mail [email protected]. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/115957 doi:10.1067/mcm.2001.115957 May/June 2001
TCM 45