WHEN PROVIDERS BECOME MEMBERSBernadette A Benta, MSHA, BSN, RN

Disease Management is a relatively young discipline that is continuously evolving. Interventions are moving away from simple care management toward adoption of tested behavior change strategies.

Programs are progressing from a focus on discrete conditions toward population health improvement. Models are adapting to better engage physicians and other providers. These shifts highlight the importance of understandingand incorporating a variety of view points as the disease management community workstogether to shape future strategies and ideals

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According to California Health Foundation about 45% of the U.S Population has a chronic health condition. About half of them-about 60 million people have co-morbidities. It is estimated that 150 million people will have at least one chronic condition in 2015.

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20062015

Traditional physician training and clinical practice focuses on meeting the needs of individual patients, whereas DM programs focus on populations.

Understandably, thetwo perspectives define different priorities and approaches to care. It is fortunate thatthe roles of physicians and disease management programs are complementary, ratherthan duplicative.

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THE ROLE REVERSAL ISSUE

Health Care Professionals are taught strategies for communicating with patients throughout the clinical encounter.

However, of course there are circumstances in which the physician or nurse becomes the patient. This relationship at times presents unique challenges.

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As is the case at the bedside or in the office setting, these challenges also arise when the goal is to enroll and keep health care providers engaged in Disease Management and other such programs in Managed Care.

The term Provider=physician, nurse, or other health care professional

The term Member=recipient of care, patient

The Provider-Member=the health care professional who is also the recipient of care

THE CARE DELIVERY SETTING OR METHOD

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REASONS BEHIND THE ISSUE

MAINTAINING BOUNDARIES BETWEEN RELATIONSHIPS WITH COLLEAUGES OR BETWEEN ROLES AS PROVIDERS/COLLEAGUE/FRIEND

AVOIDING ASSUMPTIONS ABOUT PATIENT (MEMBER) KNOWLEDGE AND HEALTH BEHAVIORS

MANAGING PROVIDER-MEMBERS’ ACCESS TO INFORMAL CONSULTATIONS, PERSONAL TEST RESULTS, AND OPINIONS FROM OTHER COLLEAGUES

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THE MYRIAD OF THE REALTIONSHIPS PROVIDERS HAD WITH THEIR PEER-MEMBERS CREATES CONFUSION FOR THE THEM IN DETERMINING WHAT THEIR ROLE WAS IN INTERACTING WITH THEM, REGARDLESS OF THE SETTING.

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STRATEGIES FOR ENGAGING PROVIDERS IN DISEASE MANAGEMENT PROGRAMS

Ignore the provider-member’s background

Acknowledge the provider-member’s background and negotiate care

Allow the care to be driven primarily by the provider-member

Use evidence-based guidelines and best practices when communicating and setting goals

Have representatives from the health plan’s Clinical team engage with population in person for regularly scheduled informative sessions about the programs

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ACKNOWLEDGE THE MEMBER’S BACKGROUND AND NEGOTIATE CARE

Negotiating the care plan will probably take a little bit more effort in some cases. For instance asking for input regarding what may have worked in the past in addressing a health problem. Open communication may allow the provider-member to choose how much they wanted their own knowledge to affect the care they received.

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CARE DRIVEN BY PRIMARILY BY THE MEMBER

A third strategy was to allow the provider-member to have the majority of the control in health care decision-making. Participants would go along with the requests of provider-member more than they would with other members unless it was contradictory to their philosophy of care. Our Care Team already uses SMART goals which is based on the same concept.

This strategy often resulted in providers offering special favors for their provider-members or altering their strategy of care to accommodate the provider-member. It also may allow the provider-members greater access to care outside of the structured medical encounter than those who tended to ignore the background.

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CARE DRIVEN PRIMARILY BY THE MEMBER IN OUR SETTING

FOR OUR DM, CM, AND ALC PROGRAMS IT IS ALWAYS THE GOAL TO HAVE THE MEMBER BE FULLY PARTICIPATORY IN THEIR CARE GOALS SO THIS MAY BE TO OUR ADVANTAGE AS WE ALREADY USE THIS TECHNIQUE.

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EVIDENCE BASED PRACTICE

Health care professionals respond to what may is proven to be effective and “cutting edge”.

Our Care Engine is driven by Evidence-Based Medicine

Additionally accessing clinical information based on evidence-based practice, clinical guidelines, medical effectiveness, pharmaceutical therapy, new technology, screening and preventive services, outcomes research, and the National Guideline Clearinghouse is a good idea.

Key Question 1. In adults with chronic medical illnesses and complex care

needs, is case management effective in improving: Patient-centered outcomes, including mortality, quality of life, disease-

specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care?

Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior?

Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)?

Clinical Questions Addressed to Consider

Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99.Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

Clinical Questions Addressed by This Comparative Effectiveness Review

Key Question 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of co morbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk?

Key Question 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers?

Hickam DH, Weiss JW, Guise J-M, et al. AHRQ Comparative Effectiveness Review No. 99.Available at www.effectivehealthcare.ahrq.gov/case-management.cfm.

There is the need for a practice-based champion with data at hand that health care providers trust.

Just as peer groups are utilized for people suffering from the same disease. Roundtables could be held with provider-members and the clinical plan representatives.

The goal would be to build relationships with their “peers” and have the program benefits discussed in these settings. The opportunity for the provider-members to give their input in this environment may foster engagement.

PEERS TALKING TO PEERS

The challenges associated with caring for a health care professional tends to get easier with experience. Explicitly communicating with the provider-member to ensure boundaries are maintained, assumptions about the provider-member are avoided, and ensuring that plan provider access is properly managed are key to providing quality of care to provider-members.

DISCUSSION

IN ADDITION TO ADOPTING THE STRATEGIES DISCUSSED, TRAINING COULD BE PROVIDED TO PROVIDER-MEMBERS ON AN ONGOING BASIS SO THAT THEY ARE AWARE OF THE “BUY IN” OF THEIR PEERS. TRUST IS OFTEN FURTHER FOSTERED WHEN FACE TO FACE INTERACTIONS ARE A PART OF THE PROGRAM.

There is limited literature available on the challenges health care providers face when caring for their peers. Rather articles tend to be general reviews on providers care-seeking behaviors.

CONCLUSION

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Sliverman JD, Kurtz S, Draper. Skills for communicating with patients. Oxford, UK: Radcliffe Publishing, 2005

http://www.ahrq.gov

RESOURCES AND REFERENCES