Getting and keeping patients enrolled in DM programs has always been a challenge. But the advent of phone-call screening mechanisms such as caller ID, and the tendency of many people to rely on their cell phones rather than hard-wired phones, has made this task doubly difficult. However, there are strategies than can help healthcare organizations overcome such obstacles and establish lasting relationships with the people who can most benefit from DM interventions.
Although DM enrollment tactics always need to be customized to fit individual organizations and patient populations, experts in this field stress that the same key considerations apply in most situations. Further, regardless of the method used to reach a patient, the timing of this connection is almost always central to whether or not that participant will enroll and engage.
Timing and training make a difference
It is critical to act upon referrals for DM quickly—particularly because claims data, which often identify patients as eligible for a DM program, are already dated by the time an actual referral is made. Debra Leon, president of Wheeling, IL-based Health Contact Partners, Inc., an independent call center, spoke about the importance of “cycle time” at HCPro’s March 13 audioconference “Enroll, Engage, and Retain: Strategies to Boost Disease Management Program Participation.”
“If a member has an event that puts him in the hospital or qualifies him for a program, obviously he is going to be more [motivated] to join the program if you can reach him within thirty days,” she says, noting that cycle time is the time period between receipt of a referral and completion of the enrollment process. “For most programs, the goal should be to [reach and enroll] identified patients within 10–14 days. Seven to 10 days is ideal.”
Leon emphasizes that enrollment success can be enhanced if you send potential enrollees a card or a letter in the mail, introducing the program and encouraging inbound calls, prior to your first phone call. “That is very helpful to people who need to know who you are,” she says. Leon emphasizes that outbound calls should be made almost immediately after that letter or card is received. “Complete the first call to everyone on your list within three business days,” she says. “If there is a two- to three-week gap, it is a meaningless effort. You have wasted the letter. They are going to forget you.”
Organizations that don’t have the manpower to look up incomplete or incorrect phone information about potential enrollees should consider using an outside vendor, according to Leon. Similarly, she advises organizations to get the help they need in order to make contact with all potential enrollees quickly.
If the people making the enrollment phone calls are nurses or other clinical professionals, that will add credibility to the encounter. However, Leon suggests that the more important consideration is making sure that these individuals have the training and skill set to perform a function that is similar to high-level customer service.
Further, she stresses that the enrollment team needs top-level support for its success. “If upper management does not see the enrollment/engagement piece as critical, and they will not invest in the training and resources needed to make it successful, that will be a barrier,” adds Leon.
Listen for subtle clues
Often, the people who stand to benefit most from DM intervention are the hardest to reach because of language barriers, odd work hours, limited access to—or comfort with—technology, or geographic isolation, according to Brenda Schmidt, MS, MBA, the managing director at Phoenix, AZ–based Diversity Wellness, a company that specializes in reaching out to diverse populations—especially in Latino communities. Schmidt, who also spoke at the HCPro audioconference, notes that in order to reach diverse populations, you need to dig beyond the simple, demographic details. “It is very easy to look at age, gender, race, ethnicity, and even job type. What is less obvious, but very key to the engagement process is literacy level, preferred language, and the preferred way of getting information—things that aren’t [readily] available to an enrollment person when they are looking at a census,” says Schmidt. “So the enrollment/engagement process needs to start very, very early in digging deeper into some of these issues.”
In particular, she notes that language specificity is a huge challenge among Latino populations because a Spanish word that may mean one thing to a person of Mexican descent may mean something completely different to someone of Puerto Rican or Central American descent. Consequently, important health messaging can be completely misconstrued or misunderstood if the person doing the outreach fails to appreciate these differences.
Similarly, whether or not a person can read has a strong bearing on how you can most effectively communicate with him or her, but Schmidt notes that alert outreach personnel can usually discern this information by listening for subtle clues. “When we do an outbound phone call around literacy level, we don’t ask the individual whether he or she can read these materials. We ask them whether they would prefer for us to read the materials to them, or to review the material with them,” says Schmidt, noting that this method enables enrollment personnel or nurse counselors to ascertain literacy status without causing embarrassment or discomfort.
Consider cultural values
Although increasing numbers of Americans are turning to the Internet for health information, that is not necessarily a valid trend among certain ethnic populations. For example, Diversity Wellness did a survey among Latino women who had access to high-speed Internet applications and found that fewer than 2% use the Internet to obtain health information. Consequently, a Web-based outreach or intervention would not be successful in this population. Other cultural groups may have different preferences. The bottom line, notes Schmidt, is that it is important to find out about such preferences before launching an outreach effort.
Similarly, she emphasizes that it is critical to understand that cultural beliefs can play a strong role in health behavior. The more outreach workers understand about these beliefs, the better able they will be to reach a population. For example, she notes that many cultures have a sense of fatalism with regard to their health. If a person’s grandfather and father have diabetes, he or she may feel it is inevitable that they will get the disease as well. Obviously, an enrollment effort that makes no attempt to acknowledge this underlying belief has little chance of success with this individual.
Sometimes it is a matter of understanding the hierarchy of the family (i.e., just one spouse making all the decisions for the family) that is critical, and other times the cultural nuances of a particular population may have the biggest impact. But Schmidt emphasizes that you need to have more than the basic details. “During that first enrollment call, if the individuals do not perceive that the person on the phone has an appreciation or understanding of them, they will not enroll,” she says.
One strategy that has worked well for Diversity Wellness is finding people within a social network or worksite to champion a program and engage others. Such champions need to come from the culture or community that you are trying to reach, but they can be invaluable in providing support and validation for the DM effort. “They can create that trust and relationship base that makes the program more high-touch,” notes Schmidt. “The more high-touch you make it, the greater the participation will be.”
Get the clinician involved
If you can loop a patient’s provider into the enrollment process, you can dramatically improve your success with DM enrollment, according to Ray Fabius, MD, president of Chadds Ford, PA–based CHD Meridian Healthcare, which operates more than 215 worksite-based healthcare centers. In a recently published study coauthored by Fabius, investigators found that this approach resulted in a 76% enrollment rate as compared to the typical rate of 25% that is achieved through conventional enrollment methods.1
The study involved nearly 2,000 Goodyear Tire & Rubber Company employees and their dependents, who were identified through informatics as good candidates to participate in a DM program focused on improving control of diabetes, hypertension, and CAD. “After we stratified the worthy population to engage in a DM program, we actually reviewed the list with the trusted clinician[s] at the workplace so that they also could have some input on patients who might be missing, or patients who may have been rated lower or higher than they should be through our informatics process,” says Fabius. “Then we looked at [the clinicians’] schedule of appointments. Any patients who we were interested in inviting to participate in our integrated DM program—who were scheduled to have an appointment within the next 60 days—were flagged to be introduced to the program and invited to participate during the actual visit.”
Targeted patients who did not already have scheduled visits received an outbound call from one of the clinicians at the health center. Whenever possible, he notes that the call was made by a clinician who had already established a relationship with the patient.
In either case, once a patient agreed to participate in the DM program, a member of the DM telephonic team initiated an outbound call to the individual to get him or her started. However, Fabius emphasizes that investigators did not consider patients true participants until they completed a telephonic assessment, which is part of the DM program.
Approach affects engagement and retention
The approach was not only successful at engaging participants in DM. In a second evaluation that will be published soon, data will show that after several months, engagement in the CHD Meridian program fell by just 6%. Additionally, Fabius anticipates that outcomes data resulting from the active engagement in DM will be positive as well. “As you might expect, the cohort of patients who agreed to participate in the program were in general more expensive to the employer than the patients who elected not to participate, but over the study period, those two cohorts switched,” he says. “The cohort that has been participating in our integrated DM program has, on average, become less expensive than the cohort that decided not to participate.”
Fabius acknowledges that by providing full-service, primary care at the worksite, the company may have advantages that traditional, off-site care services may not have. For example, all the physicians and ancillary staff members work for CHD Meridian and follow a single formulary and benefits plan.
Further, by practicing at the worksite, the clinicians have ample opportunity to establish strong relationships with their patients.
However, the healthy enrollment numbers produced by the approach suggest that engaging clinicians in the DM process early on can deliver important dividends.
“This has really been a challenge for DM programs,” he says. But to get around it, program developers went to great lengths to make sure clinicians understood the workings of the integrated DM program—even going so far as to introduce the clinicians to the group of telephonic care management nurses that would be working with them.
The message to clinicians was that there was a program available that could supplement what they do. “By sponsoring the value of the program to their patients, the engagement rate was really solidified,” Fabius adds.
1. Frazee S, Kirkpatrick P, Fabius R. “Disease Management Engagement Rates: Leveraging the Trusted Clinician.” Disease Management February 2007.