4 Ways Aetna Identifies Cases for Compassionate Care Outreach

Monday, August 5th, 2013
This post was written by Jessica Fornarotto

People often think about an oncology diagnosis first when considering advanced illness care needs. However, Aetna’s Compassionate Care program benefits individuals across the advanced illness spectrum and across the disease spectrum — lots of patients with kidney disease, CHF, COPD and other diagnoses can and do participate, explains Dr. Joseph Agostini, senior medical director of Aetna Medicare.

During HIN’s webinar, Advanced Illness Care Coordination: A Case Study on Aetna’s Compassionate Care Program, Dr. Agostini listed four ways Aetna identifies cases for the Compassionate Care program, specialized case management that provides additional holistic and patient-centered care and support not only to Aetna Medicare members with advanced illness but to their families and caregivers.

Case identification is important for the Compassionate Care Program; you need to identify who you’re going to help. We have four ways to do this:

First, we have a claims-based algorithm that helps to identify and predict members using diagnoses that we know about and other informational data to identify patients with early to mid-stage advanced illness. This way we can reach out to them and engage them early in the process.

Not everyone has an identifiable condition prior to end-of-life, so the algorithm is never 100 percent. But it gets us there to create a cohort of patients we know are really in need. For those without a predictive algorithm, most clinicians should be able to construct a list of diagnoses and diseases to identify a potentially eligible cohort who would benefit from services in advanced illness care.

The second way we identify members for the program is through the assessments and clinical judgments of Aetna case managers. We reach out to many members — nearly one in five on an annual basis — and through those conversations we identify patients at a certain stage in illness who could benefit from engaging with a nurse case manager for their advanced illness needs.

The third way is through direct referrals from physician offices. Sometimes we get direct calls, and sometimes we have an Aetna Medicare nurse embedded in that practice who works side by side with the provider group or healthcare system and generates direct referrals.

The last way we identify cases is via self-referrals; an Aetna patient may call about another issue. We identify through the questions they’re answering whether they could have a potential need for an advanced illness-related concern.

One important thing is that our program is not designed around any one particular diagnosis. Some patients have multiple comorbidities, particularly in the Medicare population. Managing the whole person is key.

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