Highmark member Rosella has some complicated health issues.
She needs a kidney transplant and is borderline diabetic. Plus, Rosella has chronic back pain and struggles to keep track of her medication.
Fortunately, Rosella, 74, was connected with a nurse care manager through Highmark’s Enhanced Community Care Management (ECCM) program for help with better understanding and managing her complex health needs.
Launched in late 2016 with network provider Allegheny Health Network (AHN), the program is changing how patients with many interconnected health issues get support inside and outside the doctor’s office.
Although the program is available only in western and central Pennsylvania now, it will be expanding in the future. Since its inception, the ECCM program has succeeded in helping eligible members like Rosella stay as healthy as possible and avoid hospital visits (see “ECCM Program Milestones”).
Based in more than 100 AHN and independent primary care practices, the nurse care managers develop direct relationships with at-risk Highmark members and build care teams around them. The focus is continuous care coordination, ensuring members can access services in the appropriate place and at the right time.
Rosella’s nurse care manager, Gina, is embedded right in her primary care physician’s (PCP) office. So each time Rosella sees her doctor, she visits Gina too.
Rosella’s PCP worked with Gina to develop a customized care plan. They saw that Rosella needed extra coaching to understand how kidney failure affected her body and how dialysis would help.
“The doctor and I talked to Rosella, explained each step and process, and related it back to her health,” Gina said.
Rosella eventually agreed to dialysis. So Gina coordinated Rosella’s kidney dialysis treatments. And to address Rosella’s back pain, Gina set up appointments with a neurosurgeon and a pain specialist.
Along with closer care coordination, nurse care managers help ECCM-enrolled members learn to better self-manage their health conditions.
That’s important because these members use nearly 50% of health care resources, although they represent about 5% of Highmark’s total membership. They also have a 70% chance of being in the hospital within six months.
But ECCM results show that when Highmark members get connected with a nurse care manager, their likelihood of ending up in the hospital decreases. Participating members have seen up to a 30% reduction in inpatient admissions and a 10% to 20% reduction in emergency department visits since the program started.
And participating members are pleased with the results: To date, 93% of members rated their nurse care managers as “very good.”
The support Gina provides to Rosella isn’t only available at the doctor’s office.
They talk on the phone every day. Gina also visits Rosella in her home regularly, providing ongoing guidance to ensure she’s following her doctor’s treatment plan.
For example, Gina helps sort through Rosella’s medications to ensure she’s taking them correctly and on time. Without such assistance, Rosella had often missed doses of her medication and struggled with pain.
Gina also ensures Rosella keeps track of her upcoming doctor visits. And Gina is there if Rosella needs a ride to her appointments.
“We discuss where she needs to go, what she needs to eat, and what concerns she might have,” Gina said.
If Gina sees that Rosella is due for a flu shot, Gina will call her to get it scheduled. And Gina watches for any changes in Rosella’s condition.
“It’s about preventing the problems before they happen,” Gina said.
With Gina around to answer questions and schedule appointments, Rosella feels more confident about managing her own health.
She’s found it easier to follow her doctor’s advice. She feels better and can stay independent. And Rosella has avoided trips to the emergency room.
Plus, she is able to do things she couldn’t do before — like prepare meals for her family and be more involved in her grandkids’ lives.
Gina feels good knowing she’s helped Rosella get on track with her health. And the two have become friends in the process.
“I want Highmark’s members to know that I’m more than a care manager,” Gina said. “I’m someone who actually cares about you.”
Note: Highmark and its employees don’t give medical advice, treatment, or diagnosis. The member’s physician or health care professional will provide all advice, treatment or diagnosis. The nurse care manager helps the member through support and coordination so that the member can effectively manage his or her health conditions. Health plan coverage is subject to the terms of the member’s health plan benefit agreement.