Guiding seniors through EOL processes
Seniors covered by BlueCross BlueShield of Tennessee's Medicare Advantage plan are guided through the end-of-life processes by case managers who empower the members with the education, resources, and assistance they need to make their own decisions about what kind of what kind of care they want to receive at the end of life.
The Chattanooga-based health plan end-of-life (EOL) planning program received a bronze award in fall 2010 at the Best Practices in Health Care Consumer Protection and Empowerment awards ceremony from URAC, a Washington, DC-based organization that promotes healthcare quality through its accreditation, education, and measurement programs,
The program began in 2009 after the health plan started its Medicare Advantage program in 2006, says Alice Greer, RN, BSN, CPHQ, quality research analyst in quality management, who was a case manager at the time. "As we worked with the Medicare population, we realized that end-of-life concerns are a big issue. We found that even though some of the members knew they were facing a potentially terminal illness, they hadn't thought about end-of-life plans, or if they had, they didn't have a legally appropriate form or had not shared their wishes with their family or their physician," Greer says.
At the same time, the insurer determined that many staff members were uncomfortable initiating a conversation about EOL considerations and needed education to learn how to approach members about their choices. "We looked for ways to assess our Medicare population to identify people who needed the program and to aid the case managers in bringing up the subject with members and leading them through the process," Greer says.
The case managers who work with the Medicare Advantage members have been trained on how to approach the subject and have information at their fingertips to educate the members. The health plan also collaborated with the non-profit Tennessee End-of-Life Partnership and sponsored a daylong educational program for case managers and the health plan's providers.
When seniors sign up for Medicare Advantage, the health plan sends them the health needs assessment. They can return it by mail and have it scanned into the computer program, or they can call and complete the assessment over the telephone.
Referrals come from the health needs assessment, from the utilization management department, from claims data that show members with multiple hospital admissions, and from the health plan's predictive modeling. The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage to conduct an initial health needs assessment. "We tweaked our assessment and configured our computer system so it would automatically send out a referral when someone had a condition that indicated they might benefit from an end-of-life discussion," Greer says.
Any Medicare Advantage member who is referred to case management is asked if they have EOL plans and if they would like to discuss the subject. Those who meet the criteria for needing immediate EOL support are offered a more intensive care plan, Greer says. Criteria for the intensive care plan include debility, failure to thrive, cancer patients with a terminal diagnosis or uncontrolled symptoms, advanced heart disease patients, advanced pulmonary diseases, dementia, end-stage liver or renal disease, and neurological disorders.
The utilization management department has a trigger list of criteria. If someone calls to obtain approval for a procedure and the patient falls into one of the diagnosis categories, those nurses are trained to send a referral to a case manager, she says. The case managers make outreach calls to all members who are eligible for the intensive care planning program. They explaini the services the health plan offers, the role of the case manager in EOL planning, and how they can empower the member to make their own decisions.
If members consent to participate in the program, the case manager completes a thorough assessment that includes their current health status; their present functional status; resources they have; their caregivers; their understanding of their current level of health, diagnosis, and prognosis; information on their socioeconomic status; and any educational or language barriers. "The case managers can mail materials to the member or provide Internet resources. We go so far as to help them prepare their forms if they know what they want and don't know how to get the Tennessee state-approved forms," she says.
The Medicare Advantage staff include two social workers who help people complete the forms over the telephone or, if the member prefers, will meet with them at the health plan's Silver Life Center. The case managers obtain consent to notify the member's primary care provider and collaborate with the physician as well as the caregiver so everyone is on the same page.
When the case manager conducts the assessment, the software system automatically triggers an appropriate EOL plan based on the answers the member gives. The care plan includes automated talking points that pop up on the screen. For example, if the member says he hasn't made EOL plans and doesn't know what is available, the case manager can click on a list of advanced directions with a concise explanation of each.
The assessment and care plan is available in the health plan's software for case managers in other areas of the company and other lines of business to use. The specific assessment is geared to the senior population, but the care plan is appropriate for any age, Greer says.
The case manager helps members make all choices from all the options available, such as where they want to receive care; symptom management; bladder control; and issues such as mobility, safety, comfort, and pain. They discuss caregiver needs and stresses, as well as services needed at home if the member chooses to stay there.
The case management team spends a lot of time educating members about hospice care and palliative care and the difference between the two, she says.
One of the goals of the EOL program is to overcome the negative impression many older people have of hospice care by educating them. Some members aren't aware of the hospice benefits they have. Others don't take advantage of them because of their perception of what hospice means, Greer says. "Length of stay in hospice is incredibly short with our Medicare population. If somebody doesn't get into hospice until the last two days of their life, they've lost the opportunity to increase the quality of life, have gone through unnecessary procedures, and increase the stress on the family. Knowing about hospice and what it means saves people a lot of panic-mode trips to the emergency room for interventions and makes them feel more in control," she says.
As they work with the members, the case managers emphasize the importance of collaborating with their health care providers so the treatment team will be aware of the patients' wishes.
If patients agree to participate in the program, the case manager follows them and contacts them at least every 30 days. The patient and family members have a telephone number they can call to talk to the case manager at any time. Patients who enroll in the program stay in the program until they decide to drop out or they pass away.
Before the program began, case managers documented a discussion with members on EOL issues only 58% of the time. After the training, the figure went up to 99%. "It's hard to measure outcomes in a program like this, but we know we are making a difference because we get a lot of letters from family members after the death of a loved one, thanking us for the case manager's support. They tell us how grateful they were that the case manager support alleviated their hesitancy to accept hospice care and that their loved one was able to die at home where they wanted to be."