9 self care and decision support group

7/26/2019 9 Self Care and Decision Support Group

1/14

AHM Medical Management: Self-Care and Decision Support Programs

Objectives:

After completing the lesson Self-Care and Decision Support Programs, you should be able to:

Describe the use of telephone triage services in self-care and decision support programs

Identify some general methods that health plans can use to evaluate the effectiveness oftheir preventive care, self-care, and decision support programs

Discuss the use of integration and partnerships to improve preventive care, self-care, anddecision support programs

Introduction

In the lessonPreventive Care Programs, we described how health plans use preventive care

programs to achieve better overall health for health plan members. In this lesson, we describe the

use of self-care and decision support programs. Self-care programs focus on providing memberswith the knowledge and confidence to perform certain aspects of healthcare for themselves.Decision support programs enable members to (1) decide when and how to seek medical care

from healthcare professionals and (2) participate with providers in decisions about the course ofcare. At the end of the lesson, we explore some general strategies that health plans may apply toall of these programs, including considerations for program evaluation.

Self-Care Programs

Most health plan members experience some type of healthcare problem on a regular, even daily,basis. In many instances, these medical problems are minor ones-headaches, indigestion, cuts,

scrapes, colds, and muscle aches, for example-that members generally treat without the assistanceof healthcare professionals. However, without appropriate treatment, these conditions may cause

pain or worsen to the point where professional care is necessary. For example, a small cut that is

not kept clean may become infected and require treatment with antibiotics or even surgery. Manyhealth plans offer self-care education and training to enable members to assess healthcare

problems and, when appropriate, take care of the condition on their own.

Types of Self-Care Programs

Self-care programs typically address common symptoms, illnesses, and injuries that can usuallybe safely and effectively treated with readily available methods such as rest, changes in diet,

over-the-counter medications, or applications of heat or cold. Self-care education also helpsmembers differentiate between minor problems and serious conditions that require treatment byhealthcare professionals. Insight 4B-1 provides an example of self-care instruction that might be

distributed to members. Some self-care initiatives teach members to conduct breast or testicularself-examinations, skin cancer checks, blood pressure monitoring, and other screening tests.Health plans often combine self-care programs with preventive care and telephone triage

programs.

Some health plans also have self-care programs for members with chronic conditions that require

regular management in order to prevent pain, complications, or hastening of the disease process.Severe arthritis and diabetes are two examples of common illnesses that need proper daily care by


2/14

members in addition to services from providers. This type of self-care is often included in ahealth plan's disease management programs.

Another application of self-care education is for members who need ongoing care because they

are recovering from acute illnesses or injuries. Proper self-care for these members can speedrecovery and reduce the likelihood of complications. For example, a member's progress in

recovering from a heart attack depends in great part on how well the member complies withprovider recommendations on medications, diet, and exercise. A self- care program that focuseson cardiac rehabilitation can enhance the member's understanding of the instructions andconfidence in performing self-care.

Methods of Delivering Self-Care Information

Health plans use a variety of approaches to convey self-care education and training to members.

Common methods include member newsletters, self-care pamphlets and books, recorded


3/14

messages that are accessible by telephone, videotapes, information on the health plan's Internetwebsite, references to other relevant websites, and interactive computer programs.

The criteria for selecting an appropriate medium for conveying self-care information are similarto those described for health promotion programs. Since the information provides advice on

medical care, all material must be clinically sound according to current standards to promoteproper treatment and to protect the health plan from charges of negligent care. In addition, thepresentation of the material should be understandable by the average layperson.

While health plans often distribute some self-care information to all members, they may wish to

target some members for additional education. The health plan can check claims and encounterreports to identify members with records of inappropriate utilization of medical care.

Demographic information may also be useful in identifying members with high potential forexperiencing illness or injury and creating programs to address their needs. For example, families

with young children tend to visit providers frequently, many times for health problems that couldbe treated by parents if they knew the proper approach. Health plans can send them self-careinformation about common children's illnesses and injuries and refer them to telephone triagelines or Internet websites for additional information. Health plans may also design self-care

information for women, men, teenagers, senior citizens, or other demographic groups.1

Member Participation

When designing and promoting their self-care programs, health plan medical managementpersonnel must realize that members vary greatly in terms of their perceptions of need forhealthcare services from providers and their readiness to adopt self-care. Members who visit

providers for seemingly minor problems because they lack the knowledge or self-confidence toperform self-care are often receptive to self-care instruction. Other members would rather see aprovider because they consider self-care too much trouble or they enjoy the attention they receive

from providers and their staffs. These members may need extensive education and motivationbefore they will attempt self-care, and in many cases, the results may not justify the expenditureof health plan resources.

Decision Support Programs

Decision support services are another approach that health plans use to give members morecontrol over their own health. Members often seek care that is unlikely to improve their health

because they lack the knowledge to choose the healthcare services that are the most appropriate

for their situations. Health plans can improve member's abilities to make appropriate caredecisions through educational material and advice from healthcare professionals about specific

medical problems. Telephone triage and shared decision making are the most common types ofdecision support programs used by health plans.

Telephone Triage Programs

When medical problems occur, many consumers have difficulty judging (1) whether to seekprofessional healthcare services and (2) what type of services they should seek. For example, amember may wonder if a child's sore throat is really a symptom of something more serious, such

as a streptococcus infection (strep throat). When members experience troubling symptoms,telephone triage programs can help them determine the most appropriate approach to care.


4/14

Telephone tri age programsare phone-based services with clinical staff who provide informationto sick or injured members to help the members decide if they need to seek care immediately at

an emergency department or urgent care center, call a provider for an appointment, or treat the

condition themselves. When a situation is urgent, the staff can alert the local emergencydepartment or urgent care center of the member's needs and impending arrival. If self-care isindicated, the clinician can instruct the member on self-care treatments to relieve symptoms and

hasten recovery. The staff may also be able to authorize referrals for specialty care and expediteappointments with specialists if the condition warrants specialty care. Figure 4B-1 provides anexample of the health problems that most frequently caused the members of one health plan to

call the plan's telephone triage line.

Telephone triage service is generally available at a toll-free number during hours well beyondtypical PCP office hours. In many cases, telephone triage service is offered 24 hours a day, 7 daysa week, 365 days a year. Plans that have telephone triage in addition to self-care or health

promotion programs may integrate some or all of these services at a central call center.

The clinical staff at telephone triage services are typically nurses or physician's assistants whohave been trained specifically for this type of healthcare service. A physician with relevantclinical experience and training in managing phone triage lines generally oversees the

development and implementation of the program. The clinical staff are often assisted by


5/14

nonclinical personnel who answer calls, obtain nonmedical data (such as health plan membershipinformation), and route the calls to the clinical staff.

When a member calls with a medical problem, the clinical staff person listens to the caller'sexplanation of the problem and then asks a series of questions about the situation to help the

caller determine the seriousness of the problem and the most appropriate course of action. Forrisk management purposes, telephone triage clinical staff should not attempt to diagnose or givemedical advice. Training for staff should emphasize that their role is to elicit information about

symptoms and other aspects of the situation and then promptly refer emergencies to anemergency department or explain treatment options for nonemergency needs.

Clinical staff members use clinical decision support tools to guide them in their questions andresponses to members. These decision support tools range from manual systems with different

patterns of questions based on a member's responses to interactive computer programs thatprovide the clinical staff with information and questions suited to the situation. Regardless of the

level of technology used, clinical decision support tools should be evidence-based guidelines thatare developed in a manner similar to that for clinical practice guidelines (CPGs). The use of

scientifically sound decision support tools increases the likelihood of good clinical outcomes andprotects a health plan against charges of negligent care. Even though there may not be a physicianor pharmacist on location, the clinical staff should be able to contact these healthcare personnel

immediately if the decision support tool gives this direction or if a staff member feels thatadditional input is indicated. For example, a clinical staff member who suspects that a member's

problem is due to drug interactions may wish to contact a pharmacist.

The clinical staff member documents all information received from and given to the caller,

including the type of care the caller plans to utilize and follow-up activities that the staff shouldperform. Typical follow-up actions include

Expediting referrals and appointments with specialists Relaying relevant information about the call to a member's PCP Contacting the member and/or the provider from whom the member sought care to gather

outcomes information Checking back periodically to reassess the situation when a member has decided that

self-care is the appropriate approach

Accurate, complete documentation of calls is critical for quality management. QM activities for

telephone triage typically focus on both the quality of clinical information provided and thequality of service. For example, how did the information given affect the ultimate outcome of themedical problem? Was the caller able to speak with a clinical staff member promptly?

Monitoring the reasons for calls to telephone triage services can also be useful to the health plan's

development of health promotion or self-care programs. Suppose that the telephone triage servicereceives many calls regarding children with fevers. The health plan may decide to send self-careinformation describing the treatment of fever in children and indications for seeking professionalcare to members with children.

The full documentation of calls is also necessary for the protection of the health plan in case it is

faced with a legal suit that involves information given out by its telephone triage service.


6/14

URAC has an accreditation program specifically for telephone triage and health informationservices. This accreditation program's standards address staffing, policies, and procedures for

handling calls, including the use of clinical decision support tools, documentation of calls, follow-

up activities, and quality management.2

Even if a health plan does not seek accreditation from this agency, URAC's standards may beuseful quality guidelines for establishing and operating this type of program.

Delegation of Telephone Triage Services

Health plans often delegate telephone triage activities. Contracting with a delegate typicallyallows a health plan to implement telephone triage more quickly than developing its own

program. Since this program is conducted by phone, the delegate does not need to be in the samegeographic area as a plan's members, so many telephone triage companies operate on a regional

basis and serve multiple health plans. As a result, health plans have many potential delegates to

choose from.

When a health plan delegates telephone triage, the health plan must confirm that the delegate

Understands the health plan's medical policy and is prepared to provide triage

information consistent with this policy Employs qualified, well-trained clinical personnel Uses evidence-based clinical decision support tools

Has an effective system for rapid feedback to PCPs and the health plan on a case-by-casebasis for emergencies

Benefits of Telephone Triage Programs

Telephone triage programs offer benefits for plan members, providers, and the health plan itself.Members typically view telephone triage as a convenient, no-cost way to obtain healthcareinformation. Receiving information from a healthcare professional can relieve anxiety for

members who have a condition that is beyond their knowledge or confidence level. Members whochoose to perform self-care not only obtain treatment immediately, they also avoid the cost andinconvenience of a visit to a provider. In actual emergencies, the triage staff can calm callers and

help them take appropriate actions until they can access care from a provider.

Providers may appreciate the fact that telephone triage services address members' health concernsimmediately and help them determine the appropriate level of care. Triage services also save

providers after-hours time that would otherwise be spent taking calls from members who areuncertain about a medical problem.

Telephone triage programs may be quite effective in reducing unnecessary utilization of medicalresources, especially costly emergency services.

3However, a health plan must structure its

telephone triage program so that quality and continuity of care and member satisfaction are notcompromised for the sake of more appropriate utilization.

Shared Decision Making

Consumers' access to healthcare information has increased markedly over the past two decades.

As a result, consumers have become more knowledgeable about medical issues and more


7/14

interested in participating in decisions about their own care than in the past. To accommodatemembers' wishes to be involved in healthcare decisions, many health plans offer programs that

facilitate shared decision making. In a shared decision-maki ng program, a provider and a

member discuss care options and the provider's recommendations, but the ultimate decision aboutcare is up to the member. By educating members about their care options and encouraging themto participate in decisions when possible, health plans hope to improve members' satisfaction with

clinical outcomes and with the health plan as a whole.

Shared decision making is not applicable to all medical situations. For many illnesses andinjuries, one approach to care is clearly superior in terms of safety and effectiveness. A shareddecision-making approach is appropriate when there are multiple approaches that are generally

accepted as valid by the medical community and none of the approaches is best for everysituation. For example, in many cases of breast cancer, lumpectomy and mastectomy are bothviable options and the choice of the surgical approach depends on the member's preferences.

Other conditions that may be appropriate for shared decision making include low back pain,

benign prostatic hypertrophy, prostate cancer, infertility, and menopausal and post-menopausalsymptoms.

When informed about their options and given the opportunity to weigh the risks and benefits,many members select a relatively conservative approach to care. For example, they may elect to

wait and see how their symptoms change rather than undergoing a diagnostic test immediately, oropt for a medical treatment rather than surgery. In many instances, the interventions that memberschoose are less costly for the health plan than are the other care options that providers might have

recommended.

Health plans should exercise caution with shared decision-making programs to support the qualityof care and avoid the perception that they are simply trying to steer members toward less

expensive approaches to care. A shared decision-making program must present a full range oftreatment options (including no treatment) and the likely outcomes associated with thosetreatments in an unbiased manner.

NCQA, URAC, and JCAHO all have standards in support of members' rights to participate inhealthcare decisions.

4

JCAHO standards outline a variety of elements that should be explained to members, such as theright to be involved in all aspects of care including decisions about life-sustaining treatments or

participation in clinical trials or investigational studies.5

Approaches to Education for Shared Decision Making

By checking HRA results, claims, and encounter reports, a health plan can identify memberswhose conditions and associated care options are suited to shared decision making. In order to

participate in healthcare decisions, members need complete, current information about theirconditions, their options for diagnosis and treatment, and the likely outcomes of the different

approaches. Education for shared decision making may come in one or more of the followingforms:

Printed material Personal or group counseling from providers or other healthcare educators

Support groups, either local or on the Internet


8/14

Videotapes Audiotapes or phone-accessible audio recordings

Internet websites Interactive computer programs

Videotapes and interactive computer programs are particularly useful for explaining how a test ortreatment is performed. The approach to education for shared decision making should alwaysinclude access to healthcare personnel who can answer questions and address specific concerns.

Some programs for shared decision-making education include an assessment of a member'sknowledge to ensure that the member has a good understanding of the relevant issues.Verification of member knowledge about care options also protects providers and health plans

against charges of malpractice.

When deciding which specific shared decision-making programs to offer, a health plan mayexamine claims and encounter reports and then focus its resources on diagnostic and therapeutic

procedures that appear to be overused, based on current CPGs. For example, suppose that thefrequency of surgery for low back pain is significantly higher than national or regional rates for

that procedure and diagnosis. The reason may be that members are not aware of other treatmentoptions and the possible advantages of the other options over surgery. Information about manyconditions and care options is already available from providers, medical professional

associations, and community agencies such as the American Cancer Society. Before developingnew programs for education about care options, health plans should evaluate existing resourcesand use its own resources to meet needs that are not already addressed.

Another way that a health plan can help a member understand care options is to provide a

checklist of questions as a guide for talking to providers or conducting other research. Figure 4B-2 lists questions to help a member understand and choose among different treatment options.


9/14

Member Participation

The approach to education for shared decision making should reflect the same considerations that

we presented for health promotion programs. Readiness to participate in care decisions is acritical issue. Although many members welcome the opportunity for more control over their own

health, others are extremely uncomfortable about making healthcare decisions and prefer tofollow provider recommendations. Members may become frightened or angry if pushed beyondtheir level of confidence about healthcare, so health plans must be careful to let members

determine how involved they want to be in care decisions.

Provider Cooperation

Many providers are accustomed to making decisions about healthcare with limited input frommembers, so they may be unfamiliar with or even resistant to the shared decision-making process.By showing evidence that many members want more control over their own health and involving

providers in the development of shared decision-making programs, the health plan can encourageprovider cooperation.

Evaluation of Preventive Care, Self-Care, and Decision Support Programs

The evaluation of a preventive care, self-care, or decision support program is a complex processthat considers many different variables. One important basis for program evaluation is progresstoward specific goals. For each type of program, health plans typically identify areas for

improvement and establish goals that reflect the nature of the proposed improvement, the amountof change projected, and the timeframe for the change. Program goals often specify a subset ofthe member population. For example, a health plan's goals for a 12-month period might include

the following objectives:

10 percent increase in the proportion of members over the age of 65 who have received

influenza vaccinations 8 percent increase in participation in fitness programs by members who are at least 20

percent overweight

10 percent decrease in inappropriate utilization of emergency services 7 percent increase in the proportion of women over the age of 50 who receive a

mammogram

However, progress toward goals is not a sufficient basis for determining the overall worth of a

program. Health plans also consider other effects of the program such as changes in

Clinical outcomes Member and purchaser satisfaction Results on accreditation evaluations, HEDIS scores, and report card ratings Relationships with providers

Appropriate and inappropriate utilization Financial outcomes (i.e., the cost of the program compared to cost savings from the

program)

Ideally, these types of programs will improve clinical outcomes, member and purchaser

satisfaction, quality ratings from external bodies, and relationships with providers. Providersoften play a critical role in the success of a health plan's preventive care, self-care, and decision


10/14

support programs. A provider's recommendation that a member participate in one of theseprograms greatly increases the likelihood that the member will actually do so. Additionally, input

from providers helps to maintain the scientific soundness, timeliness, and suitability of these

programs' educational materials, CPGs, clinical decision support tools, and self-care information.On the other hand, a health plan must avoid the perception that it is infringing on providers'autonomy or interfering in their relationships with members. For example, if a telephone triage

program refers a member directly to a specialist without informing the member's PCP in a timelymanner, the PCP may feel that the health plan is interfering with the care of that member.

While these programs should decrease the incidence of members' seeking inappropriate levels ofcare, the health plan should not be surprised at increases in utilization of lower-intensity services,

such as more members receiving immunizations and screening or members making appointmentsto see a PCP rather than seeking care in the emergency department.

When considering the costs and benefits associated with preventive care, self-care, and decision

support programs, the health plan must take into account both current and future costs andbenefits. In many instances, health plans have difficulty relating cost savings and health benefits

to a particular program, especially if the health plan has all three types of programs for aparticular medical condition. Another obstacle to demonstrating medical effectiveness and cost-effectiveness is that, for many of these programs, the results may not be apparent for at least a

year and often longer. In addition, other factors may influence the results of an initiative. Forexample, a local hospital's program to encourage women to obtain mammograms may inflate theresults reported by a health plan's mammogram awareness program.

Role of Information Management in Program Evaluation

Effective information management is necessary for a health plan to measure the benefits and costs

of a preventive care, self-care, or decision support program. A health plan's information systemsmust be able to accurately collect, analyze, and report data on

The costs of providing the program to the health plan's members Clinical research evidence supporting widespread implementation of the intervention The level of member participation in the program

Changes in the utilization of other services because of the program Short-term and long-term cost savings that result from the program Clinical outcomes and member satisfaction ratings for the program

Provider satisfaction ratings Quality management initiatives and periodic measurements for the program

In addition, the information system must link the different measures in order for the health plan todetermine the overall value of a program. For example, does increased participation in a self-care

program decrease inappropriate utilization of providers' services? How much money is saved foreach dollar invested in an immunization program? Do cost savings come at the expense ofclinical outcomes or member satisfaction?

Additional Strategies for Preventive Care, Self-Care, and Decision Support Programs

The final section of this lesson provides more detail on two of the strategic approaches that healthplans may use when developing and implementing preventive care, self-care, and decision


11/14

support programs. These strategies are (1) integration of the programs and (2) partnerships withother entities.

Integration of Programs

While some health plans have separate programs for preventive care, self-care, and decisionsupport, other health plans have coordinated and integrated their initiatives for a particular health

issue to create a care continuum that encompasses a wide variety of activities. Such a continuummay also be linked to a health plan's disease management programs. In many cases, thedevelopment and delivery of integrated programs are driven by member needs identified through

HRA. An integrated approach may be targeted to a specific medical condition, such as CAD, orto a broader concern, such as health issues for a particular demographic group. Insight 4B-2

provides an example of an integrated program of prevention, self-care, and decision support

activities for peri-menopausal and menopausal women.


12/14

Partnerships with Other Entities

Health plans should also explore the possibility of partnering with other entities that have a stake

in health plan member health, such as employers, hospitals and other providers, state and localhealth departments, health-oriented community service organizations, and other health plans, for

preventive care, self-care, and decision support programs. Insight 4B-3 describes a cooperativeeffort for prevention between a health plan and the American Lung Association. Other lessobvious choices for partners are businesses that provide goods or services that may contribute to

healthy lifestyles (e.g., food manufacturers, restaurants, fitness centers), media that are interestedin public service opportunities, and churches whose members have unmet health-related needs.

Such partnerships often result in more effective programs with a greater level of participationthan a health plan could achieve on its own. Partnering also allows a health plan to share the

financial costs of a program.

Suppose that a health plan decides to partner with an employer on a fitness program. The healthplan and the employer can pool their knowledge to select the type of program and the manner of

presentation that will best address unmet employee health needs. The health plan typicallydevelops the program according to the risks and other characteristics of the employees, and theemployer can post notices and distribute reminders about the program. In some instances, the

employer may provide a convenient location for the fitness activities, encourage employeeparticipation through incentives, or subsidize the cost of the program. Increased participation inthe program may improve the overall health of the employees, and healthy employees are more

productive and miss less time away from work due to illness than employees who are less

healthy. Employer sponsorship of preventive care programs also conveys the message that the

employer cares about the well-being of its employees.

Provider partners can be invaluable for the development and implementation of preventive care,self-care, and decision support programs. As hands-on caregivers, providers may be in the best

position to know the healthcare needs of individual members and the population as a whole.Further, providers often have the opportunity to address preventive issues when a member visitsfor another reason. For example, when a teenager comes in for a pre-camp or pre-sports physical,

a PCP can conduct an HRA that looks at issues such as sexual activity, drug and alcohol use, seatbelt use, and depression.

7


13/14

Hospitals are likely partners for these programs because many of them already have experiencewith preventive care, self-care, and decision support. Hospitals have traditionally been involved

in primary and secondary prevention programs, and some hospitals manage their own telephone

triage services or conduct self-care classes such as first aid.8

In addition, members are often receptive to hospital-sponsored programs because they typicallyknow and respect the hospitals in their communities.

A health plan may also decide to share its preventive care, self-care, or decision supportexperience with other health plans for the benefit of an entire population. Programs such as the

America's Health Insurance Plans (AHIP) Innovations in Health Plans identify and publicizehealth plans' best practices for medical management. In some locations, health plans arecollaborating on preventive care programs to (1) help providers and members understand and

remember prevention guidelines and (2) improve the health of the community for the benefit ofall health plans.

Conclusion

By enhancing the care that health plan members give to themselves, health plans can improve theoverall quality of care their plan members receive and decrease unnecessary utilization of carefrom healthcare professionals. Self-care and decision support programs can also improve member

and provider satisfaction. Fewer visits to providers mean more time and money saved bymembers and more control over their own healthcare. Providers are generally supportive of self-care programs as well. Improved patient education not only contributes to better health outcomes,

it also leads to fewer visits for minor problems. Providers can focus on more serious healthproblems and improve the quality of care they deliver to their patients.

Endnotes

1. Craig S. Russell, "Targeting Approaches Affect Health Care Consumer Behavior andCost Savings," Managing Employee Health Benefits (Winter 1999): 54-55.

2. American Accreditation HealthCare Commission/URAC (URAC), Health Call CenterStandards (Washington, DC: American Accreditation HealthCare Commission/URAC,

1999).

3. Robert Mayo, "Education Can Increase Loyalty and Decrease Costs," ManagedHealthcare (August 1999): 28.

4. National Committee for Quality Assurance (NCQA), Accreditation '99 (Washington, DC:National Committee for Quality Assurance, 1998), 85.

5. American Accreditation HealthCare Commission/URAC (URAC), Health Network and

Utilization Management Accreditation Standards Interpretive Guide, (Washington, DC:American Accreditation HealthCare Commission/URAC, 1998), 72.

6. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 1998-2000Standards for Health Care Networks (Oakbrook Terrace, IL: Joint Commission on

Accreditation of Healthcare Organizations, 1998), 72-73, 76-77, 94-95.


14/14

7. "Best Practices in Women's Health: Hormone Replacement and Mid-Life Issues,"Healthplan (May/June 1999): 56-60.

8. Ibid., 336.

9 self care and decision support group

Documents