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Unique approach offers guidance to patients with low-prevalence/high-cost conditions

The idea that psychological health has a significant impact on physical health has gained traction in recent years, particularly as evidence mounts of the deleterious impact that behavioral disorders such as depression have on the chronically ill. However, for a variety of reasons, traditional health plans continue to struggle with designing care management strategies that adequately take behavioral health into account.

One organization that believes it has come up with an effective approach to the problem is Newark, NJ-based Horizon Blue Cross and Blue Shield (BCBS). The health plan already has in place a suite of 10 in-house DM programs, including one for depression, all of which provide psychosocial support along with traditional DM services to members identified with the most common chronic diseases.

But convinced that there are additional opportunities to improve care and cost-efficiency, the organization has now partnered with Tampa, FL-based Health Integrated to provide a behavioral health intervention to members with less prevalent chronic conditions, including chronic back pain, Crohn's disease, ulcerative colitis, rheumatoid arthritis, Parkinson's disease, migraines, and seizures. Called Synergy, the program aims to improve overall health and quality of life by addressing both medical and behavioral needs.

Members seek support

"There is an important psychosocial aspect to these conditions, which is very in sync with our mentality and how we are running our programs," says Sue Binder, RN, CCM, PAHM, the director of Horizon BCBS' health and wellness programs. Further, Binder notes that although the diseases may not be as common as diabetes or asthma, they are nonetheless high-cost, and members impacted by these conditions have sought additional support.

From Health Integrated's perspective, the targeted diseases make sense because they all play a critical role in the overall health status of patients, especially with respect to some of the pain disorders that patients with these diseases frequently experience, says Sam Toney, MD, chief medical officer and vice chair for Health Integrated. "Our approach, utilizing the behavioral sciences as the core foundation, and our care coaching strategies lend themselves very nicely to this suite of diseases," he says.

A diagnosis involving one of the five targeted conditions is just one of the criteria involved with the case selection process. Health Integrated runs sophisticated analyses on administrative data, which enable care managers to identify those individuals most likely to benefit from intervention.

"We reach out to and attempt to enroll that subset of the [targeted] population that we believe we will have the highest impact with, and obviously, the highest level of ROI for," says Toney. "There are clinical markers and targets, utilization patterns, and trends that we look at, so it is not simply a historical-cost methodology." Further, while a member does not necessarily have to have a psychiatric diagnostic code in the claims system to be considered for enrollment, that is one additional filtering and stratification layer that is included in the case-identification process.

Care coach focuses on 'patient-centric' goals

Engaging identified patients in the program is among the most challenging aspects because many of them have psychosocial and behavioral issues, and they tend to lack the motivation to participate.

Health Integrated tries to get around these barriers by letting patients know ahead of time that they will receive a call from a program representative. The representative then uses motivational communication strategies to describe the program to potential enrollees and obtain their consent to enroll. Roughly 60% of the people Health Integrated reaches by phone enroll in the program, says Toney.

At this point in the process, each enrollee is referred to a care coach-a licensed clinician with a behavioral health background-who will work one-on-one with the individual to address areas of difficulty and establish a roadmap for achieving specific goals. And even before the care coach speaks with a patient, he or she has a number of prepopulated data sets pertaining to the person's

  • diagnostic conditions on both the medical and behavioral side
  • medications
  • demographic information
  • providers
  • risk level as stratified by the Health Integrated system

    Consequently, Toney explains that the interaction can get off to a relatively quick start, beginning with what he describes as a motivational assessment component-named as such because it is designed to be engaging. "It is a tool not only for gathering information, but also for defining patient-centric goals, and actually beginning the patient-coaching process on the first call," he says.

    The first part of the motivational assessment is primarily concerned with psychosocial challenges. It includes a behavioral health profile, which Toney suggests is particularly important for patients who have not been diagnosed with a psychiatric condition.

    "Clinicians are able to ascertain through this profile what general areas of impairment and disability they might see with the individual relative to depression, anxiety, mania, [or other behavioral health disorders]," he says. "Once the first part of the assessment is complete, we then have already established patient-centric goals, we have already begun some interventions, and we have gathered a tremendous amount of data."

    Program includes disease-specific modules

    Care coaches turn their attention to the second part of the motivational assessment during the second call to a patient. This section focuses on disease-specific metrics and interventions, and it includes the Patient Health Questionnaire (PHQ-9) for the assessment of quality-of-life and depression. Depending on what conditions the patient has, the care coach and patient work through disease-specific modules that are derived from evidence-based guidelines.

    "If the care coach discovers that the patient has reported that his or her treatment plan is not consistent with those evidence-based guidelines, then that will yield a referral to one of our medical directors for review, and a potential intervention with the attending physician," says Toney. "When we feel we need to intervene with a provider, it is always telephonic and it is also from a specialty-based physician."

    Such communications are never directive, emphasizes Toney, but rather intended to provide attending physicians with information they may not be aware of. In fact, Toney points out that in many cases, the treatment plan is in accordance with evidence-based guidelines, but the patient does not adequately understand it.

    "When we reach out to the provider and discuss the issues at hand, the provider clarifies for us [what the treatment plan indicates], and we are then able to go back and connect those dots with the member and get the communication gap closed," says Toney. "That is a very important care coaching goal."

    Personal goals motivate patients

    In many cases, the goals patients establish for themselves are very specific or narrow, and only indirectly related to their condition. However, Toney points out that they often provide patients with the focus and motivation to take meaningful steps toward improving their quality of life, and this can lead to larger improvements in health status.

    For example, Toney recalls the case of one patient with low back pain who established the goal of being able to take walks every Saturday with his grandchildren. In working with this patient, the care coach discovered that he was not adhering to his physician's treatment regarding pain medication and physical therapy. The care coach helped the patient to realize that by adhering to the treatment recommendations, his pain could be reduced, and he ultimately was able to achieve his goal.

    "It has been an interesting time for us in connecting these dots for the patients, and recognizing that the primary goals that they have identified on the front end may not be the goals that most people would recognize as most important, but in reality they are the most important goals because they are what get these patients to move and change behavior," says Toney.

    Guidance & encouragement help

    Working as a care coach in the Synergy program, Shelly Watts, LMHC, says that she spends a lot of her time helping patients learn to solve problems. "Pain is a factor that comes up over and over again, whether it involves rheumatoid arthritis, migraines, or whatever, and I often encounter people who used to be really active, and now they can't be, and they are really grieving the loss of that," she says.

    In these instances, Watts helps patients identify activities that they can do. Additionally, she may refer them to a physical therapist or another specialist for consultation, and she often works with patients on coping strategies that can help distract them from their pain. "[We focus on] anything that can improve their quality of life by either reducing their pain or finding ways to manage it," adds Watts. Another goal that comes up frequently in her work with patients is a desire to lose weight, says Watts. "If this is not their primary goal, it is their secondary goal, and I am often asked how I can help them do that over the phone," she says. "It is really a matter of assessing their strengths, and really trying to play up to those because a lot of people are really just discouraged, or maybe they don't have a lot of support."

    In many cases, Watts notes that just having someone on their side who can make suggestions and provide encouragement helps patients feel better about themselves and make progress.

    Staff collect and report data

    The Horizon BCBS Synergy program has just begun, but based on work Health Integrated has done with other clients, the average length of stay in the program is 12-18 months. However, Toney emphasizes that patients remain in the program until they have achieved the following key goals:

    1. They are adherent with their treatment plan

    2. The treatment plan is in accordance with evidence-based guidelines

    3. Behavior changes are sustained

    Health Integrated built these triggers into its information system so that care coaches receive an automatic prompt to consider discharge when patients have reached the indicated goals.

    However, Toney emphasizes that program staff continuously track many additional clinical and financial parameters including

  • symptom severity trends
  • PHQ-9 scores
  • hospital and ER utilization
  • overall medical costs
  • patient and provider satisfaction

    Health Integrated publishes these data points in quarterly or annual reports for clients to review.

    Additionally, clients receive monthly activity reports that include enrollment and discharge data.

    Early results show promise

    Based on studies looking at earlier implementations of the program, Toney anticipates positive results with Horizon BCBS as well.

    "We have managed close to 18,000 patients through this program," he explains, noting that the first iteration, unveiled two years ago, focused exclusively on depression. "We realized early on that with effective management of depression, we see a significant offset on the medical side."

    In one early study of the impact of the program on a cohort of 1,100 people, for example, Toney says the program was associated with a 20% decrease in hospital admissions, and an 18.3% decrease in annual, per-member medical costs.

    "[These results] are the primary reason why we decided to move this program and evolve it into a more comprehensive, global, med-psyche or medical-behavioral initiative," he says.

    One reason for the program's success may be related to the extent to which PCPs have accepted the intervention.

    "I would have expected some resistance from the physicians, but they are pleased that there is someone who is going to be working with their patient, and collaboratively with them as well," says Binder.

    Toney believes this acceptance is partly because many physicians refer their patients to behavioral health specialists, but the patients are reluctant to follow up on those referrals. "Consequently, we become like extenders to that PCP from a specialty perspective, and it has been very positive and very well received," he says.

    Going forward, Toney envisions further refinement of the approach, with the possible inclusion of additional disease states, and there are also initiatives in place to enable Web-based outreach to patients. "We are looking at both the expansion of the clinical scope as well as the technological scope."

    Editor's note: For more information about Health Integrated or its Synergy program, visit the organization's Web site at www.healthintegrated.com.