Posts Tagged ‘advanced illness’

Aetna Compassionate Care: “Advanced Illness Care Coordination Can’t Be Measured by Numbers Alone”

September 30th, 2014 by Patricia Donovan

In its new report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” the Institute of Medicine recommends the development of measurable, actionable, and evidence-based quality standards for clinician-patient communication and advance care planning to reflect the evolving population and health system needs.

Aetna’s Compassionate Care program, a case management approach for individuals in advanced stages of illness, breaks down barriers commonly encountered in this highly sensitive stage of the health continuum while positively impacting both healthcare utilization and spend. Here, Dr. Joseph Agostini, senior medical director, Aetna Medicare, shares some best practices from Aetna’s Compassionate Care Program.

There are several best practices. First, there is training, which is integral to the success of the Aetna Compassionate Care program.

Second, there is the proper selection, mentoring and ongoing learning opportunities for nurse case managers. These include such things as ongoing online tutorials, in-person training, where everyone gets training in change management and motivational interviewing techniques, regular ‘lunch and learns,’ medical director sessions including case-based rounds of cases that are in progress right now and feedback sessions. We bring in external entities to provide specialized expertise as necessary so that nurses get continuing education throughout the process.

Another best practice for us is having Aetna case managers manage all types of members. We don’t have a specialized unit that just specializes in advanced illness care needs. We think all of the nurse case managers should have developed this critical skill of being able to manage those with advanced illness, but also be able to identify support and be advocates for patients in all phases of their lives.

We also use a variety of functional status and prognosis tools. Many of these rating scales are scores focused on functional status. That’s important to follow over time, and can be predictive of outcomes. In our program we don’t necessarily use all of these scales, but we always capture some basic functional status over time and it’s useful and necessary to view that longitudinally.

A real-life example captures the heart of what we do. A case manager writes:

‘Wife stated member passed away with hospice. Much emotional support given to spouse, she talked about what a wonderful life they had together, their children, all of the people’s lives that he touched. They were married 49 years last Thursday and each year he would give her a piece of jewelry. On Tuesday when she walked into his room he had a gift and card lying on his chest, a beautiful ring that he had their daughters purchase. She was happy he gave it to her on Tuesday; on Thursday he was not alert. She stated through his business that he touched many people’s lives and they all somehow knew he was sick and he has received many flowers, meals, fruits, cakes. She stated her lawn had become overgrown and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice is wonderful, as well as everyone at the doctor’s office and everyone here at Aetna. She tells all of her friends that when you are part of Aetna, you have a lifeline.”

And the case manager concludes, “Encouraged her to call with ongoing issues or concerns and closed to case management.”

You can really feel the depth of connection that develops between the Aetna member, or the family caregiver and the case manager. You can’t really make this happen; it occurs over time and I would suggest to everyone that advanced illness care coordination can’t be measured by numbers alone or on hospital admissions or the length of time in hospice. We need to develop quality measures that capture the degree of family, caregiver and patient support that a program like this engenders.

advanc care planning
Dr. Joseph Agostini is the senior medical director for the Aetna Medicare team. He is responsible for medical management strategy, clinical initiatives, and provider collaboration oversight for Aetna Medicare members.

Source: Case Management for Advanced Illness: Best Practices in End-of-Life Care

4 Ways Aetna Identifies Cases for Compassionate Care Outreach

August 5th, 2013 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.

Infographic: End-of-Life Care in California

May 17th, 2013 by Patricia Donovan

Californians, like many Americans, frequently do not get the kind of care that they want at the end of their lives. This infographic from the California Healthcare Foundation documents research on end-of-life care for Medicare beneficiaries, and analyzes it in light of what is known about Californians’ preferences for care as they approach death.

The research found sharp variation that cannot be explained by differences among patients in age, sex, or race.

End-of-Life Care in California

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

You may also be interested in this related resource: Case Management for Advanced Illness: Best Practices in End-of-Life Care.

Aetna’s Compassionate Care Program Incorporates Holistic, Member-Centric Case Management

June 22nd, 2012 by Cheryl Miller

When a loved one is dying, continued support and compassionate care from clinicians and case managers can be a “lifeline,” at least to one member whose spouse went through Aetna’s Compassionate Care program.

And that’s one of the main goals of the program, according to Dr. Joseph Agostini, senior medical director for Aetna Medicare, who spoke to the Healthcare Intelligence Network during its Advanced Illness Care Coordination: A Case Study on Aetna’s Compassionate Care Program, a 45-minute webinar on June 13, 2012: to provide additional support to members with advanced illness and their families/caregivers, and help them access optimal care, so they can get more of the kind of care they want, and spend less time in the ICU and hospital.

A person has advanced illness if

“…he/she has one or more conditions that progress enough that general health and functioning decline, and treatments begin to lose their impact.”

Aetna’s Compassionate Care Program is a nurse case management initiative that specifically targets patients with advanced illness, and it has had a major effect on healthcare utilization and quality outcomes, he said.

The need for such a program is crucial, Dr. Agostini said, given the increasing number of elderly people with advanced illness. Studies show that:

  • The rate and rise of older Americans is growing, and 10,000 baby boomers are aging into Medicare a day; and
  • The rate of Americans 85 years and older is growing; and
  • An estimated 30 percent of Medicare costs are incurred in the last year of life; and in the last month, 80 percent of costs are for hospitalizations; and
  • While most deaths occur in the hospital or nursing home, most Americans prefer to die at home.
  • While not a goal, Dr. Agostini stresses, the Aetna Compassionate Care program has increased hospice selection rate.

    The program relies on nurse case managers to identify members for the program, and then to act as a support system for them and the community supporting them.

    There is no specific training, instead, Aetna employs a “holistic, member-centric case management plan,” and RN case managers “should have the ability to support patients through all phases of life,” says Dr. Agostini. “Addressing patients holistically is crucial, because comorbidity is common, “ he explains. According to a JAMA study, people at the end of life value different things, including freedom from pain, and having family present, and Aetna’s goal is to honor the differences.

    Case managers can help members to understand their options, address pain and other symptoms, help plan advanced care support, and provide education and awareness of resources and online tools. Training is key, Dr. Agostini says, and includes motivational interviewing, technical training, and “lunch and learns.”

    Aetna’s involvement in compassionate care was prompted by significant gaps in care for the elderly, especially end of life care. Part of the problem is a serious shortage of specialists: data shows there is one oncologist per 141 new cancer patients versus one palliative medical doctor for every 1,200 patients with serious or life-threatening illnesses.

    And there are definite benefits to introducing palliative care options sooner. According to a study from the Dartmouth Atlas of Health Care, patients pursued less medically aggressive care but lived more than two months longer, had fewer depressive symptoms and improved mood and quality of life. The explanation could be that “earlier referral to hospice could lead to better symptom management.”

    As with any program, there are certain endemic challenges, including inadequate pain treatment, late referrals, difficulties determining prognosis, and lack of emotional support.

    But overall the program has resulted in significant results, including:

  • 82 percent reduction in acute inpatient days; and
  • 77 percent reduction in ER visits; and
  • 86 percent reduction in ICU days; and
  • Improved quality of life for Aetna members and their families.
  • This last result was perhaps most important for the member who reported on her husband’s passing in hospice while in Aetna’s program. Two days before their 49th anniversary he gave her a piece of jewelry that his daughter had helped him to purchase; it was something he’d done every year since they were married. Two days later he lost consciousness, but she expressed gratitude to the team for having been given this final memory.