1. From Wellness to Disease Management: Covering the Health
Care Continuum
2. Reality Check
The top three causes of death are heart disease, cancer and
stroke; The leading cause of all three is. A.) High Blood Pressure
B.) Fatigue C.) Obesity
The director of the Behavioral Medicine Research Center at
Baylor College predicts what percentage of Americans will be
overweight or obese by 2040. A.) 50% B.) 90% C.) 75%
What percentage of US adults do not engage in any leisure time
physical activity. A.) 40% B.) 25% C.) 60% (Department of Health
and Human Services)
An American Cancer Society report shows obesity and lack of
physical activity causes how many cancer cases in the United
States? A.) 1/5 B.)1/2 C.) 1/3
3. For Every 100 Employees
4. 60 are Sedentary
5. 25 Smoke
6. 64 are Obese/Overweight
7. 27 Have Heart Disease
8. 10 Have Diabetes
9. 50 Have High Cholesterol
10. 24 Have High Blood Pressure
11. 50 Are Distressed or Depressed
12. Small changes, Big Impact
Reducing one health risk can
Reduce absenteeism by 2%
Improve productivity by 9%
Reference: Pelletier B, Boles M, Lynch W. ( 2004). Change in health
risks and work productivity over time. J Occup Environ Med.
13. Activation!
Our level of personal activation (Take Chargedness) determines
our behavior, our risks, our likelihood to change, and our medical
costs.
Diet
Exercise
Disease specific self-management
Consumeristic behaviors
14. Increased health risk, increased cost Impact of Modifiable
Risk Factors on Medical Expenses Annual adjusted medical expenses
ie. Overweight individuals cost 21% more than those whose weight is
in the healthy range Adapted from Goetzel RZ, Anderson DR, Whitmer
RW, et al, Journal of Occupational and Environmental Medicine (40)
(10) October 1998, 1-12
15. Care Management: Every Day Health
Integration between systems, people, programs
Lifelong support for members at any health stage
Simplification for member, employer, physician
Transformation of health care system
CareEnhance Health Coach Special Beginnings Disease Management Case
Management SUPPORT FOR EVERY DAY HEALTH WELLNESS COACHING SUPPORT
MANAGEMENT
16. CareEnhance: Decision Support The difference
betweenwondering what to do and knowing.
17. CareEnhance: Decision Support
24/7 toll-free phone access to registered nurses
5 call centers and support for more than 100 languages
Help knowing when, where (or whether) to seek care
Library of over 1,100 prerecorded health topics
Program reminders mailed to members quarterly
Administered by McKesson Health Solutions
.
18. Health Coach: Lifestyle Change The difference
betweeninaction and taking charge.
19. Special Beginnings: Healthy Pregnancy The difference
betweenworry and peace of mind.
20. Special Beginnings: Healthy Pregnancy
Nurses provide one-on-one member support
Assess each members risk to determine education and
outreach
Members choice of pregnancy book or DVD (Spanish options)
What to expect during pregnancy and birth
Signs of premature labor and other complications
Tailored pregnancy information
24/7 phone access (CareEnhance after hours)
Engine rewards for completing program
21. Case Management: Advocate, Navigate The difference between
going it alone and having a trusted advisor help you through.
22. Case Management: Advocate, Navigate
Support for serious illness or injury
One-on-one nurse support based on conditions
Nurses advocate, navigate and coordinate care
Promote optimal quality
Match resources to needs
Avert unnecessary expenses ($20 million in 2005)
1% of members drive 30% of health care costs
Reminder: Case managers can help members understand their
conditions, work with multiple providers and make the most of their
benefits.
23. Disease Management: Change the Future The difference
between an existence controlled by your condition and taking
control of your life.
24. Disease Management: Change the Future
Targets diabetes, cardiac, and respiratory conditions
AdviCare packages may cover additional conditions
Prevent or postpone complications
Nurses and clinicians offer one-on-one support
Interventions based on members risk level
Newsletters, care reminders, phone contact, other outreach
Support treatment plans and improve compliance
Improved clinical measures and outcomes
Help members understand and manage their condition(s)
25. Disease Management: Change the Future
Disease management is the difference between...
BEFORE Uncontrolled Diabetic with Non-Healing Wound 3 Office Visits
$ 375 Hospital Admission $25,000 Surgeon Fees $ 6,000 Prosthetic
$12,000 Rehabilitation $24,000 Insulin $ 6,000 TOTAL $73,375 AFTER
Controlled Diabetic 6 Office Visits $ 750 Foot Care $1,100
Dietician $ 300 Physical Therapy $ 500 Insulin $4,500 Pharmacy
Services $ 110 TOTAL $7,260
26. Why Regence Disease Management Matters
45% of members with chronic conditions do not receive
evidence-based care*
Medications, tests and exams, doctor visits
Improve diet and exercise
Reduce stress
Engaged members make better health care decisions
Improvements in quality of life may
Increase productivity
Reduce absenteeism and presenteeism
Slow cost trends over time
*Source: McGlynn, et al., New England Journal of Medicine, 2003
.
27. Regence Disease Management Basics
Targeted conditions
Diabetes
Coronary artery disease (CAD)
Congestive heart failure (CHF)
Asthma
Chronic obstructive pulmonary disease (COPD)
Depression
Anxiety
Prevents or postpones complications
Supports treatment plans and improves compliance
Helps members understand and manage their condition
28.
29. Having A Chronic Illness Is Complicated Only about 20% of
people with health conditions do what they should to maintain good
health
Take Medications
Do Prescribed Tests
Visit Doctor Regularly
Reduce Stress
Exercise
Follow Diet
30. Physicians Have Challenges, Too
Health care systems have driven physicians to fix patients, not
maintain their health
Lack of time with patients
Increasing prevalence of chronic conditions
Shift to short term episodes rather than long term health
status.
Our goal is to support the physician with patient behaviors between
office visits
31. We Stratify the Population
Stratification of Risk
Rules-based algorithms
Individually stratifies the population so we know where to
start
Low Risk High Risk
32. We Apply the Right Level of Intervention
4 levels of risk stratification
Program tailored to risk level
Fluid stratification algorithms (claims, prescriptions,
updates, self report, physician and care calls)
Interventions based on member specific needs and best practice
guidelines
Level of intervention is based on individual stratification and
risk status of the member
33. What do members participating in the program receive?
AdviCare participants will be offered:
One-on-one nurse-based counseling
Support through telephone calls designed to help the member
through coaching and education
Members talk by phone with a knowledgeable
RN who:
One-on-one nurse-based counseling
Understands the complexities of their conditions
Can take the time to answer all of their questions
Has access to a variety of educational materials
34. We Address the Whole Person
Its about people, not the disease
Understand individual behaviors and help the participant modify
them
In order to create change you must establish unconditional
credibility and positive intent
Set goals with the patient that are achievable
Build on their successes
All co-morbidities and behaviors must be managed simultaneously by
the same trusted relationship
35. We Extend the Physicians Reach
Expanded interventions between office visits
Comprehensive health condition protocols (evidence based
standards of care)
Behavioral modification
In market nurses supporting practice patterns with tools and
education
A primary goal of our program is to support the physician with
patient behaviors between office visits
36. Outcomes Reporting
Financial semi-annual report reflects pre- versus post program
results
Clinical Outcomes semi-annual report on members overall
compliance with selected standards of care
Utilization semi-annual with % change in admissions, length of
stay, ER visits and bed days
Member Satisfaction - annually
Activity quarterly report showing members counts and
type/frequency of member contact
Note: Client level reporting varies based on group size.
37. Program Results Health Care Cost for Diabetes Population
Declined During Years 1 and 2 both in Real Terms and when Compared
to Adjusted Base Period Costs Year 1 Trend is 7% Year 2 Trend is
12%
38. Diabetes Clinical Indicator Improvement
39. Results
43,492 Program participants
677,940 Educational mailings
186,088 Telephonic interventions
Office Visits ALOS (days) ER visits Admissions Bed Days Utilization
Other Professional Pharmacy Outpatient Inpatient Overall Costs 6.56
6.0 263 157 938 $45 $97 $106 $58 $145 $431 Intervention 6.93 5.2
307 206 1,061 $47 $137 $118 $118 $147 $551 No Intervention -5% 13%
-14% -24% -12% -4% -29% -10% -51% -2% -22% % Change
40. Member Satisfaction Percent of Members Rating the Program
Good to Excellent Member satisfaction with healthcare increases
steadily so you hear less noise. 78% 89% 78%
41. Success Story
Diagnosed with type 2 diabetes for over a decade.
During a Welcome Call, she told the AdviCare nurse that upon
receiving her AdviCare diabetes workbook,she read it from "cover to
cover." She stated more than once how pleased she was with it; in
comparing it with others she had read, she found AdviCare's to be
"more readable" and to contain "better dietary information" than
others she had read. She reported that despite her long time
diagnosis, she looked forward to participating in the AdviCare
program.
42. Making a Difference in Someones Life
A member had a history of substance abuse and uncontrolled
diabetes prior to her calls from the AdviCare program. For four
years she had not been having regular laboratory testing or reviews
of her medications. In 2005, the AdviCare nurses sent her workbooks
and encouraged the member to review the standards of care. The
member also set a goal to call member services and find a physician
to help her manage her diabetes. Since then the member has had her
medications reviewed, her annual exams, and A1C testing. She has
continued to remain sober and stated she attributes her current
health with diabetes to the information and support provided by the
AdviCare nurses.