Chronic illness self-management puts patient in charge
The one who controls an individual’s healthcare is not the doctor, the health plan, or population health company. It’s the individual patient.
That sentiment is catching on as the disease management (DM)/population health industry tries to create a system that goes beyond nurse call center programs. Population health has already expanded into technology, remote patient monitoring, and automated call centers as a way to supplement the costly call center–based system. The next step in the process is putting the patient in control, says Kevin J. Widenhaus, PhD, director of behavior science and data analytics at HealthMedia, Inc., an Ann Arbor, MI–based healthcare company that specializes in combining technology and behavioral science to emulate a health coach via the Web.
The progression is needed because the current healthcare system does not prevent illness and disease, Wildenhaus says, adding that chronic illness self-management programs move away from member education to empowerment and away from information to intervention.
Progressive population health organizations understand the need to empower the patient with support from the healthcare support system, Wildenhaus says, adding that the future of population health is in emphasizing prevention and wellness, such as incorporating behavioral health programs as core components of the program. With chronic illness expected to inflict 164 million people in the United States in 2025, call center–based programs won’t be an economically viable option, he says.
“The only way you can provide population health is to take this approach that the patient has to be at the center. It’s the only viable way to do it financially and economically from a scalability perspective and a behavior change perspective,” says Wildenhaus, who spoke about the topic at the November 2008 DMAA: The Care Continuum Alliance conference.
Studies show that phone coaches only improve patients’ behavior for a short time and put them into a passive rather than active role in their health, Wildenhaus says. Traditional DM interventions intensify after a hospitalization or other healthcare interaction via outbound telephonic interventions. There is little intervention for those who are healthy or at risk of a particular disease.
Through the chronic illness self-management model, behavior change interventions continue across the care continuum via a Web-based program, Wildenhaus says. (See Figure 1 on p. 9 and Figure 2 on p. 10.)
HealthMedia’s Care for Your Health program is a Web-based chronic illness self-management program that emulates a health coaching session—without a coach—to deliver an individually tailored condition-specific management plan.
Wildenhaus says the following are ways to motivate people in self-management programs:
“We really focus on the fact that many times, those external factors are what will bring people into a program or an initial step to take responsibility,” Wildenhaus says. “But in order to sustain or maintain it, you need to move people into an intrinsic driver.”
The self-management program asks people what internally and externally motivates them. The program teaches the difference between the two motivators and helps drive them to intrinsic value by tying it to values and give them the skills and techniques to overcome barriers.
Eight steps to self-management
Wildenhaus says there are eight elements to a successful chronic illness self-management program. Participants should:
It’s important to personalize the program so the individual is given information that interests him or her, Wildenhaus says. It’s one thing to place health information on a Web site. It’s quite another to make it something that people can integrate into their lives.
For example, rather than add dozens of links to the member’s home page about various types of disorders and health tips, customize the menu to include only items of interest, such as specifics about particular ailments, illnesses, and lifestyle choices. A 30-year-old mother of a small child is most likely more interested in early childhood and new mom programs, so populate the member’s page with links to those programs. Alternatively, a 75-year-old woman with high blood pressure is more apt to read articles about hypertension and elderly ailments, such as osteoporosis and falls.
“That’s why we get such a high response rate in terms of people feeling the program was tailored to them, reading the information completely, sharing with others, etc.,” says Wildenhaus. “We take out all the stuff that is not helpful to them or not necessary, and we boil down the essential thing in a tailored way that they would most need, want, and benefit from.”
This can be accomplished by gathering information from an individual’s health risk assessment and claims records and asking the individual to input information such as weight, body mass index, medications, and doctor visits. Through that information, Care for Your Health creates a member-specific Web page. Employers can also help by giving incentives for employees to visit their health Web pages.
Highmark Preventive Health Services, a Pittsburgh-based health insurer, implemented HealthMedia’s Care for Your Health program as part of its DM offerings, which includes the Blues on Call Condition Management, a 24/7 nurse phone line that helps members with chronic disease manage their conditions.
Connecting to the individual patient is an important way to spark change. There is already a slew of health-related information online, and most people know about healthy food and lifestyle options. The problem is that they still don’t follow the advice, which is where creating an individualized message comes into play, says Wendy R. Vida, RD, clinical preventionist at Highmark.
Many people don’t understand how healthy choices affect them or foster behavior change, but the Care for Your Health site has tailored information for the individual with specific calls to action, Vida says. Highmark’s members have increasingly turned to the Web to access the insurer’s programs, and the company is looking to grow online, she says.
“The program is definitely growing. One of the things we are charged with in the division of preventive health services is to grow all the online programs every year, and we have special goals around that,” Vida says. “We are always looking to increase those numbers.”
Online programs are also less expensive options than call centers for population health companies and insurers trying to save money, as telephonic coaching comes with personnel costs. Alternatively, creating personalized Web pages is a cost-effective way to reach members, Vida says.
With so much talk about the medical home model and questions about whether population health has a place in the concept, Wildenhaus says chronic illness self-management could easily become part of a redefined medical home model. Self-management is not an attack on physicians’ autonomy, but helps patients during the time they are not in the doctor’s office.
In addition to relaying condition-specific interventions to the individual member, HealthMedia tries to improve doctor-patient relationships and medical adherence. Care for Your Health seeks to improve patients’ relationships with physicians by helping patients develop questions to ask doctors during office visits and to remember their advice.
Highmark study shows positive results
HealthMedia’s chronic illness self-management program has shown success. HealthMedia and Highmark conducted a study to see how the Care for Your Health program was helping members self-manage their conditions and improve their relationship with physicians and pharmacists.
More than one-quarter of the Highmark members who enrolled in the Care for Your Health program had high cholesterol, high blood pressure, and/or allergies. More than 30% had one chronic condition, and 28% reported two chronic conditions.
The study found that Highmark members were pleased with the program, as nearly 97% rated the program positively. (See Figure 3 on p. 13.)
The study found that more than 90% of members said they had a better understanding of their role in managing conditions and were better able to self-manage their conditions 90 days after starting the program. Nearly 90% said they were better able to communicate with their healthcare provider.
Nearly the same amount of members said their health improved because of the program, that they took full advantage of the health resources available, and were better able to manage their stress.
Members said the quality of their health improved, as well as their motivation and confidence levels to manage health and take their medications as prescribed. (See Figure 4 on p. 14).
A medical claims analysis showed that the Highmark program saved nearly $1,000 on medical claims per member annually compared to projections and that the program’s return on investment was $1.65: $1.
Is self-management the end of call centers?
Although a Web-based program saves money on personnel, human intervention is not completely eliminated by implementing self-management programs, Wildenhaus says.
Nurse call centers and other DM human-based interventions will continue to play a role in case and care management. The difference in a chronic illness self-management program is that a nurse call center will play a complementary role rather than a primary one.
The nurse call center model as the primary method is not possible because of limitations in “reach, scalability, and cost,” Wildenhaus says. The call coach or phone nurse will “serve a supportive function and will support the functioning of autonomy and personal accountability in the patient, which is a very different model than the education model,” he says. “Accountability and responsibility has to go beyond just giving people information or educating them about their condition because knowledge is not sufficient for behavior change. I think that has borne itself out over and over again, which is why the future is going to be very different from the past.”