Healthways - High Risk Care Management: Hospital Avoidance / Cost Reduction Program

Healthways is the leading provider of specialized, comprehensive Health and Care SupportSM solutions to help millions of people maintain or improve their health. Healthways' programs are designed to help healthy individuals stay healthy, mitigate and slow the progression of disease associated with family or lifestyle risk factors and promote the best possible health for those already affected by disease. Their proven, evidence-based programs provide highly specific and personalized interventions for each individual in a population, irrespective of age or health status, and are delivered to consumers by phone, mail, internet and face-to-face interactions, both domestically and internationally.

Situation

Medicaid plans strive to offer continuous, comprehensive, high quality care to their recipients -- traditionally under served children, families and individuals. At the same time, these plans are often targets for budget cuts. This can be attributed to poor connectivity and inability to fully engage members who are then unable to follow through with their treatment plan due to external factors.

A small California-based Medicaid plan contacted Healthways stating these common problems and seeking a solution for their population. After reviewing their data, we recognized an opportunity to target a percentage of their high cost members with our High Risk Care Management program.

Our experience with this Medicaid population was similar to most health plans; however, we found that compounding the complex medical conditions for these members were difficult social and financial situations. These members often lacked strong support systems, appropriate coping skills and had lacked a history of success in many aspects of their lives.

These members are typically not in need of disease management services but do require assistance with care coordination, psychosocial issues, access to care and transportation. For these members, a comprehensive case management approach is the best option.

Solution

Healthways' High Risk Care Management (HRCM) Program, is an advanced disease-agnostic care program for a health plan?s highest risk participants (.5-1% of a Medicaid population, or 3% to 5% of a Medicare population) who are living with medically complex conditions and require short-term, intensive and individualized one-on-one health action planning to avoid imminent hospitalization. This approach is very effective with all ages, including pediatric and senior members.

In the HRCM program Healthways targets members based on their risk for high cost acute care utilization. Many of these individuals are struggling with multiple co-morbidities and medically complex plans for care. We take a holistic approach to a member's health, adding a trust-building relationship with an assigned nurse, who works with the member's primary care physician. This collaboration results in educated, empowered and stabilized members. We target high-risk members that have multiple psychosocial and clinical issues as:

• At risk for hospitalization in the next year
  
• Diagnosed with multiple chronic conditions
  
• Facing social and psychological challenges
  
• Deteriorating clinically
  
• Unfamiliar to their PCP
  
• Receiving uncoordinated care
  

From a program perspective, the goal of the high-risk care management program is to reduce overall health care cost trends by raising the functional status and optimizing care for a health plans most frail and needy members. The program is designed to help members avoid hospital admissions and produces typical first year results including:

• Reduced cost of the high-risk population 20% or more
  
• Improved functional status 15% to 20%
  
• Reduced overall hospital utilization 5% to 10%
  
• Reduced overall medical loss trend by 2% to 5%
  
• Improved process of care for the least stable plan member

Better Health Lower Costs

The small California-based Medicaid plan contracted with Healthways for our High Risk Care Management program.

Despite the challenges these members faced, deficient support systems, inappropriate coping skills and a history of failure in many aspects of their lives, our program was successful with this population due to our primary focus, which is to help the member become more self-reliant.

We accomplished this by helping them achieve quick incremental successes that we built upon while working towards larger behavioral and lifestyle changes. The key to our success is a one to one relationship between the nurse and the member. We have structured the relationship to be a temporary support while helping the member build other sustainable supports in his/her life. Though we may not be able to change the health and social issues these members face, we are able to equip them with tools and skills to manage their health and life situation. Below is our experience with this Medicaid plan after a twelve-month period.

• 35% decrease in Admission/1000 for the HRCM members
  
• 15% decrease in the Emergency Room (ER) visits/1000
  
• 25% improvement in the members’ perceived functional status.
  

HRCM Soft Outcome: A 70-year-old male diagnosed with colon cancer and anemia was prescribed Procrit on a weekly basis. He was not able to get the medication for the past three weeks from his pharmacy and his physician felt the need to admit the patient. The High Risk Care Manager was able to work with the health plan pharmacist and the Rx drug company to locate the billing problem. The patient had his Procrit delivered to his home within 24 hours of solving the problem. The patient did not require admission to the hospital and his blood count is back to normal.