Population Health & Chronic Disease

Patients dealing with chronic conditions such as multiple sclerosis, diabetes, COPD, congestive heart failure and kidney disease face many challenges, which can be compounded if underlying psycho-social issues prevent them from complying with treatment and engaging in effective self-care. In addition to negative health outcomes, the healthcare expenditures associated with noncompliant patients who are struggling with chronic disease can be staggering.

CareOregon, a nonprofit care management organization, worked with Health Integrated, a data-enabled care management company, to implement a targeted population management program designed to maximize patient capabilities and improve compliance and health outcomes. Portland State University conducted an independent review of the results of Health Integrated’s program and found, in addition to reporting high rates of patient satisfaction, 98.8% of program participants received outpatient wellness visits, compared to 79.2% of all CareOregon members. Click here for Figures.

Targeted Population Management
Health Integrated’s program is designed to provide additional support and assistance to people with complex chronic health conditions via personal contact with licensed medical professionals by telephone. Health Integrated evaluates health plan members and selects candidates who are most likely to benefit from the program, then matches them with an experienced personal clinician to help them set goals, cope with stress and learn more about managing their conditions. Clinicians build relationships with patients, making sure they have access to appropriate care services and maximizing their self-care capabilities.

In Health Integrated’s CareOregon program, 20 different conditions were included for management. After agreeing to participate, CareOregon patients were given the choice to receive personal phone consultation from a licensed medical professional or to receive educational health mailings only. To assess how the program was working for patients, surveys were conducted to explore patient satisfaction with the program, their progress with managing their conditions, their healthcare utilization rates and effectiveness of doctor-patient communication. Survey data were combined with health information that was analyzed using Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Population Health & Chronic Disease Survey and Hedis Analysis Findings
As the patients who participated in the program are dealing with chronic conditions — often with more than one serious condition at a time — it is unsurprising that survey participants rated their health status as much sicker than the general CareOregon Medicaid population and that they reported high healthcare utilization and low effectiveness in self-care.

However, program participants reported positive changes in their health, and, importantly, better communication with their doctors. In addition to elevated levels of exercise, better eating habits and more confidence in self-care, one of the main goals of the clinicians is to improve doctor-patient communication. Program participants said they engaged in meaningful conversations with their personal clinicians about communicating with their physicians and that they had gained confidence in their ability to minimize their chronic health condition’s impact on their daily activities. They also reported that their clinician was an important resource.

An analysis of HEDIS measures showed that members who participated in the program had better outcomes on almost all of the metrics studied. Patients who engaged with personal clinicians via telephone had higher rates of screening and prevention measures and diabetes care than those who received mailed materials only or those who declined to participate. Program participants also achieved higher rates of COPD/asthma management.

Overall, 96% of survey participants reported that they were either satisfied or very satisfied with their personal clinician, and 80% believed their clinician made a difference in how they handled their health issues. Those who participated in the program reported a 98.8% rate of receiving outpatient wellness visits as compared to 79.2% for all CareOregon members. These findings strongly suggest that Health Integrated’s program is not only a resource that patients value but that it delivers measurable improvements in compliance, which is a vitally important component of effective chronic disease management.

Zachary Fritz is executive vice president, Sales & Marketing, Health Integrated. With a distinguished background in sales and client service management, Zac focuses on strategies that deepen the Health Integrated’s role as a trusted adviser to Medicare, Medicaid and commercial health plans and provides comprehensive compliance, care management and revenue optimization services to Co-Ops and plans participating in the Exchanges. Previously, Zac was vice president and general manager for Truven Health Analytics, Ann Arbor Mich., and senior vice president, sales and marketing, at MyHealthDIRECT, Brookfield, Wis.

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