Blue Cross Nurses Manage Provider’s New Follow-up Care Program
New Mexico Business Weekly
April 13, 2012
by Dennis Domrzalski
Blue Cross and Blue Shield of New Mexico Care Management specialist Yvonne Venti picked up the phone recently and called an insurance plan member who had just undergone a major surgery.
During the conversation, Venti noticed signs that the woman might be suffering from depression. In a subsequent e-mail exchange, the patient confided that she had low self-esteem and was indeed depressed. Venti put the patient in a case management program that provided the patient with follow-up care.
Five months ago, that conversation would not have taken place because Blue Cross had no system in place to track what conditions might cause patients to be readmitted to a hospital or to be on the path to a chronic illness.
But in December, after two years of study, Blue Cross, which insures 300,000 New Mexicans, launched its Care Coordination and Early Intervention program. It’s designed to flag conditions that could lead to more serious illnesses, and to intervene to prevent those more serious conditions from developing.
The program has been launched in four states by Blue Cross’s parent company, Health Care Services Corp., which runs Blue Cross plans in Illinois, Texas, Oklahoma and New Mexico and insures 13 million people.
“They did a claims history on two year’s worth of data and discovered a pattern – that there were certain diagnoses and conditions that triggered hospital readmissions and avoidable emergency room visits,” said Cynthia Al-Aghbary, senior director of Health Care Management for BCBSNM.
“They developed a list of 1,500 to 2,000 diagnoses and procedures that are high-risk for hospital admissions, readmissions and emergency room use. Anyone who receives one of those diagnoses is automatically put into the program for a nurse to manage.”
Daily, Venti is given a list of eight to 12 patients whose conditions warrant intervention. She calls them and explains the program, which is free and voluntary, and asks if they want to participate.
“I have about a 98 percent positive reaction rate. Most people...thank us for having the program,” Venti added. “We can follow them for 45 days in the program. If they need continued care, we can refer them to behavioral health, case management, lifestyle management and disease management programs we have here.”
The program is available to all of Blue Cross’s commercial and Medicaid members. It involves nurses who will go to a member’s home to ensure that, after a hospital stay, the patient has all the post-discharge information they need, including information about their medications. Venti makes follow-up calls to determine whether a patient is taking those medications or has any problems getting them.
The program is necessary because of the way health care has changed over the past several decades, Al-Aghbary said. Years ago, people had family doctors who had hospital privileges and who got patients admitted to hospitals when necessary. Those doctors kept close track of their patients and engaged in follow-up care, she added.
Today, however, the doctor-patient relationship has changed, and a doctor might not know for weeks that a patient was in the hospital.
“A lot of our doctors in rural areas have said that it takes them weeks before they get a copy of a patient’s discharge papers from a hospital, and sometimes they don’t get notice of a readmission,” Al-Aghbary added.
“You don’t have your doctor going to the hospital anymore to see you, so there is a disconnect there, and that is a universal problem in health care. We want to make sure that our providers are aware that their patients have been in the hospital and that they get discharge instructions and can follow-up in a timely manner.”
Blue Cross doesn’t yet have data to show how the program is working and if it has prevented hospital admissions, readmissions and emergency room visits, Al-Aghbary said.
Presbyterian Health Plan, which insures 400,000 New Mexicans, is in the process of developing a plan similar to what BCBS offers, a Presbyterian spokeswoman said.
The 200,000-member Lovelace Health Plan launched a followup care program for Medicare patients in June. The In-Home Care Program is designed to keep elderly patients out of the emergency room and to reduce hospital admissions. Elderly patients are visited once a month by nurse practitioners who review their medical conditions and do health assessments. To date, more than 1,500 assessments have been completed, said Lovelace spokeswoman Laurie Volkin.
So far, the most common diagnoses and procedures that show up on Venti’s daily list of patients are hip and knee replacements, back, brain and heart surgeries, amputations and any kind of cancer.