From Wellness to Disease Management: Covering the Health Care Continuum

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• From Wellness to Disease Management Covering the
  Health Care Continuum

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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

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For Every 100 Employees
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60 are Sedentary
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25 Smoke
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64 are Obese/Overweight
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27 Have Heart Disease
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10 Have Diabetes
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50 Have High Cholesterol
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24 Have High Blood Pressure
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50 Are Distressed or Depressed
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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.
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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

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Increased health risk, increased costImpact of
Modifiable Risk Factors on Medical Expenses
ie. Overweight individuals cost 21 more than
those whose weight is in the healthy range
Annual adjusted medical expenses
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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

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CareEnhance Decision Support
The difference betweenwondering what to do and
knowing.
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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

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Health Coach Lifestyle Change
The difference betweeninaction and taking charge.
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Special Beginnings Healthy Pregnancy
The difference betweenworry and peace of mind.
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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

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Case Management Advocate, Navigate
The difference between
going it alone and
having a trusted advisor help you through.
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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.
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Disease Management Change the Future
The difference between an existence controlled
by your condition and taking
control of your life.
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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)

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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
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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.

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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

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Having A Chronic Illness Is Complicated

• Take Medications

• Reduce Stress

• Follow Diet

• Exercise

• Do Prescribed Tests

• Visit Doctor Regularly

Only about 20 of people with health conditions
do what they should to maintain good health
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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
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We Stratify the Population

• Stratification of Risk
• Rules-based algorithms
• Individually stratifies the population so we know
  where to start

High Risk
Low Risk
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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
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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

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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
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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
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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.

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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
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Diabetes Clinical Indicator Improvement
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Results

• 43,492 Program participants
• 677,940 Educational mailings
• 186,088 Telephonic interventions

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Member Satisfaction
Percent of Members Rating the Program Good to
Excellent
89
78
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Member satisfaction with healthcare increases
steadily so you hear less noise.
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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.

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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.

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Thank you for attending

• Jennifer Havlin, BA, BSN, RN
• Regence BlueShield
• [phone]
• jxhavli_at_regence.com