Posts Tagged ‘Motivational Interviewing’

Improve Medication Adherence, and Payors Pay Attention

June 20th, 2017 by Patricia Donovan
medication adherence

Training in motivational interviewing helps Novant health set medication adherence goals that are meaningful to patients.

Seeking additional dollars from managed care contracts? Work harder at getting patients to adhere to medication therapies, advises Rebecca Bean, director of population health pharmacy for Novant Health. Here, Ms. Bean describes ways her organization is improving medication adherence, including pharmacist referrals, while enhancing Novant Health’s bottom line.

Medication adherence is a huge focus for our organization. There are some quality measures related to adherence, including CMS Star measures. They are triple-weighted, which indicates they mean a lot to payors. Often, medication adherence is a way to get additional dollars through managed care contracts. Our pharmacists work hard at helping patients adhere to medication therapies.

We have found some benefit to using adherence estimators. Adherence estimators give you a better feel for what is causing the patient to have difficulty with taking their medication. The other finding is that oftentimes providers are unaware; they have no idea patients aren’t taking medications. This becomes a safety issue; providers may keep adding blood pressure medications because they are not getting that blood pressure to goal. If for whatever reason the patient suddenly decides to take a medication they weren’t taking before, there could be a serious issue with taking all of those blood pressure medicines at one time.

The other benefit to estimating adherence and identifying root causes is that it frames the discussion with the patient. I don’t want to spend an hour talking to a patient about why it’s important to take this blood pressure medicine when it’s actually a financial issue. If I know it’s a financial issue, then I can make recommendations on cost-saving alternatives. It helps you to be more efficient in your conversation with the patient.

The other challenge of adherence is that patients are reluctant to be honest about this issue. You have to be creative to get the answers you need or get to the truth about adherence. If you flat out ask a patient if they’re taking their medications, most of the time they will say yes.

One other helpful strategy when working with patients to set adherence goals is to have them set goals that mean something to them. It’s not helpful for me to set a goal for a patient. If I ask them to tell me what they’re going to do, then they’re accountable for that. It is very helpful to get your staff trained in motivational interviewing. This trains them to meet the patients where they are and to understand what is important to that patient, which helps you frame the medication therapy discussion.

Source: Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations

pharmacists and medication adherence

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

Overcoming ‘Clinical Inertia’ and 7 Other Barriers to Remote Patient Monitoring

February 26th, 2015 by Cheryl Miller

It’s important to identify potential barriers from both patients and providers before implementing a telehealth program, says Susan Lehrer, RN, CDE, associate executive director of the telehealth office for the New York City Health and Hospitals Corporation (NYCHHC), because both groups need to change behaviors. Resistance to change is universal, and if you’re changing any kind of work flow or communication, there will be initial resistance.

  • Slow buy-in and some resistance by clinicians (referrals).
  • Clinicians concerned with appearance of decreased productivity.
  • Resistance to change in clinic work flow.
  • Inability to “integrate” Web site data and electronic medical records (EMRs).
  • Language and literacy.
  • Complexity of chronic disease management.
  • Lack of protocols for use of email in coordination of care.
  • Not all clinicians utilize secure email system.
  • Source: Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management

    Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management profiles a successful eight-year initiative by New York City Health and Hospitals Corporation’s (NYCHHC) House Calls Telehealth Program that significantly lowered patients’ A1C blood glucose levels. Susan Lehrer, RN, BSN, CDE, associate executive director of the telehealth office for NYCHHC, shares key aspects of the real-time monitoring program, including how the program blends telehealth, electronic medical records, electronic communication with providers and direct communication with patients by nurse case managers, and much more.

    Infographic: Motivational Interviewing

    November 19th, 2014 by Melanie Matthews

    Motivational interviewing (MI) is a standardized, evidence-based approach for facilitating behavior change, according to a new infographic by Health Sciences Institute.

    The infographic explores the four key phases of MI and evidence to support MI’s impact.

    Evidence-Based Health Coaching: Patient-Centered Competencies for Population HealthTo succeed in a value-driven system, healthcare organizations will need to shift primary responsibility for health management to the individuals it serves. Evidence-based health coaching supports these population health goals by aligning best practice care with patients’ needs and values.

    Evidence-Based Health Coaching: Patient-Centered Competencies for Population Health presents a template for evidence-based coaching that emphasizes clinical competencies, along with real-life applications from a health system already utilizing clinical health coaches within its value-based healthcare network.

    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.

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    What’s Your Motivational Interviewing Communication Style?

    May 6th, 2014 by Patricia Donovan

    MI is increasingly favored by case managers and health coaches to elicit behavior change.

    There are three distinct communication styles in motivational interviewing (MI), a directive, client-centered counseling style designed to invite or elicit behavior change specifically by helping individuals to explore and to resolve ambivalence toward specific behavior change. Today, motivational interviewing is favored not only by health coaches but also by case managers and physicians. Here, the three styles are defined by Dr. Karen Lawson, MD, program director for the health coaching track at the Center for Spirituality and Healing, University of Minnesota.

    Directing, which is familiar to any of us who come from a conventional, medical or therapeutic background, is about getting specific information, making informed recommendations — basically telling someone what their next step should be and what they should do. There is an important place and role for that in healthcare, and it should by no means be eliminated.

    From a coaching standpoint however, when someone is truly wearing the hat of coach, I do not believe for the most part that directing should play a significant part in what they’re doing. There may be a moment or two in time where delivering concrete information that they happen to have that could be of use to a client, may be appropriate, but that should be a very small percentage of the time that’s spent in a health coaching session.

    Looking at the second style, the opposite of directing is following, where you truly are with no agenda, structure, or input, openly listening and following where the client wants to go. There’s definitely a role for that in coaching; however, coaching should be 100 percent following.

    The place in the middle is guiding. Health coaching done from this perspective with an MI framework is a guiding relationship.

    For example, a teenager who has diabetes may have many complex situations going on. They’re often very resistant, and trying to find a way to both manage their adolescence and their diabetes at the same time. It’s very common for the physician, in a directive way, to say, “How many times are you taking your insulin? How often are you checking your blood sugar? What are your numbers running? This is what you should do to fix the situation.”

    By comparison, a coach working with a client like that might be able to say, “How do you feel that you are doing with your sugar management? What do you feel you might be able to do if you would like to take that blood sugar management up to a better level? Would you like to do that, and if so, how would you do that?”

    There’s still some guiding in there that occurs. It’s not only listening generically; guiding does occur, but it’s cognizant of not delivering clear, dictated instructions.

    Excerpted from Health Coaching for Behavior Change: Motivational Interviewing Methods and Practice.

    Meet Healthcare Case Manager Lori R. Young – Treating Each Patient Like a Work of Art

    March 4th, 2013 by Cheryl Miller

    This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

    Lori R. Young, RN, CCM, Case Manager Mid-America, North Flex Medical Team

    HIN: Tell us a little about yourself and your credentials.

    (Lori R. Young:) I’ve been a nurse for more than 25 years. I have a current RN license in both Georgia and Florida, and recently obtained my certification in case management, which I enjoy very much. When I began with Aetna about seven years ago, I spent my first four years in disease management. I was one of six core nurses chosen for a large employer customer team. Only six nurses out of the entire disease management team were chosen, so that was quite an honor in itself. I was also the nurse chosen to meet Ron Williams, our CEO at the time. They selected one nurse for him to talk with and see how we do things, and what our workflow was. Meeting Ron and having that experience was a wonderful experience.

    What was your first job out of college and how did you get into case management?

    I have actually been a nurse since I was 15 years old. I started in South Florida as a candy striper in a geriatric home there. I would write letters for patients, hold their hands while they were having their blood pressure done. That is how I began in nursing, solely on a volunteer basis.

    Seeing the difference that caring and respect made had a big impact on my life. I’m a very positive person. I’ve been an artist for the past 25 years, and that does play into this. Each piece I do is unique and it’s how I view my patients and my members.

    What kind of art do you do?

    I use multimedia. I am a gourd artist; gourds are natural products and I do high-speed carving, including a seasonal Santa Claus line. Three or four years ago I did a show for HGTV, I was one of six artists featured, and it was the greatest time. I also create a line of jewelry with my mother; she is in Florida, and we make bracelets for the battered women’s facility there. My mom presents them to people who have nothing. And I also make glass; I turn it into what appears to be stained glass. I created an entire line of these and gave them as gifts to a group of nurses I worked with; each piece had their names carved into the glass.

    That’s in my midnight hour. It’s so relaxing to do nursing and case management all day long on a full-time basis and have that time of relief. And I think it actually makes me zero in even further the next day when I go to work.

    Has there been a defining moment in your career, perhaps when you knew you were on the right road?

    There have been so many it’s hard to pick just one. I assisted a family with two children; I was assigned to be the father’s case manager after he had an acute MI. It was the scariest night of this family’s life, and the mom said it was a night that changed their life around. She wrote a letter to Aetna and dedicated a song to me, She’s an Angel, by Alabama.

    I still get tears in my eyes when I feel like my patients are holding my hand over the phone or they bring me into their personal lives and tell me how their grandchildren or their elderly parents are. I believe that is such an important part in what we do.

    In brief, can you describe your organization?

    I am extremely proud to work for Aetna. It’s a company that has helped build and shape America for over the past 160 years. I respect our leadership in (Aetna CEO Mark) Mr. Bertolini and those who work with him. It was about 1850 or 1853 when Mount Aetna erupted, an 11,000-foot volcano in Sicily that led to the naming of Aetna. To this day I still feel such pride and passion in working with them because I feel they shape America on behalf of our members, the communities they serve, and their endless efforts to give. They’re the first ones there when a tragedy strikes. I just can’t say enough for my company, for our company and its leadership.

    What are two or three important concepts or rules that you follow in case management?

    Privacy is one of the most important concepts, whether you’re in an elevator or whether you are standing with your friend on the corner and talking. We have a very large population of baby boomers and late baby boomers and you just never know who is standing next to you in an office or elsewhere.

    People are so unique onto themselves, just like my art pieces – their expectations, their level of knowledge of procedures, techniques, doctors, personalities, the healthcare system itself. There’s so many complexities that each and every person has to absorb; I think proper assessment, and respecting privacy is very important.

    I also believe that collaboration between our departments, between our managers, and our higher management is important; that we talk to each other on behalf of our efforts towards each member of patient. What do they need? We can’t be afraid to talk to each other or that it’s going to take too much time.

    Lastly, most of us are telephonic, and it is important that our members or my patient knows my sincerity, and the smile on my face. I want to treat every single person like they’re the 8:30 call of the day. I want them to feel that. I don’t want them to think I’m too busy to hear something very important, or that they’re just going to throw something by me and see if anybody cares, and if they get a response. I really do want to be that person that hears them.

    What is the single most successful thing your organization is doing now?

    With the changes coming in healthcare, there’s a great deal of fear among people: fear of the unknown, fear of whether their children, as they get older, will have insurance. Do they even know what a socialized system is? Do they know whether or not this is going to become the system? Aetna wants to be the forerunner. They want to get it right. And they want to get the information correct and get it out to the people as easily and thoroughly as they possibly can. Aetna Navigator is a tool that our members have access to with private ID and password. It’s a very secure site that each year is becoming more and more user friendly. And reaching out on a community level is very important. I believe there is a great need for Aetna to come to the neighborhoods.

    Do you see a trend or a path that you have to lock onto for 2013

    The trend that I’m seeing is providing an increased knowledge base to our communities and our existing members. Helping them to understand. It’s difficult for most of us that have been in healthcare for 25 and 30 years; it is quite complex. And to do this not only in a multilingual sense — we have a language line that is just sensational – but to provide people with the most accurate, easy to understand information. I’m going to use ‘accurate’ as the first word, because they hear so much from so many sources, and so many of them depend just on the television. My goal would be for Aetna to provide these people with a better understanding of where we’re headed.

    What is the most satisfying thing about being a case manager?

    Being a case manager is multifaceted. It is being able to be the patient’s advocate and assist them and their families with their healthcare benefits, and help them utilize their benefits to the maximum degree.

    And the most important thing is, again, to let them hear my voice, to let them know how much I care. This is not just a business transaction. This is their life, their family’s life, and I really care that we do this right.

    What is the greatest challenge of case management and how are you working to overcome this challenge?

    One of our greatest challenges is patient load. We are a very busy team and no matter how busy, we still assist other teams when needed. No matter how busy I am, when I speak with a person I don’t look at a clock. Our case managers’ time management skills are sensational for everything from technical problems (the biggest thing that can slow us down) to the patient who needs to talk for 90 minutes versus the patient who only needs five minutes. Time management is a great skill that case managers must possess. And, the case manager must maintain a balance: after you finish with that 90 minute member, the next person should feel like they’re the first one of your day. And that’s a fine balance.

    What is the single most effective workflow process, tool or form case managers are using today?

    The most important tool we have is collaboration. It is the greatest tool that I know of, to collaborate with my peers, medical directors, supervisors, and it all requires excellent time management. If you have spent 10 minutes, or you have clicked three times to reach what you’re after and you’re still not there, reach out. Manage your time. We all get caught up in it sometimes. We want to be successful in our search of that unique thing, but as a team, it’s best to be time efficient and reach out to your peers.

    We also have a Wiki, which identifies a complete workflow, and we have our central sites that we go to. Aetna has provided unlimited resources – (PS2) performance tools if we need them – if you have a very difficult case and want to look at that discharge plan and get your flow down just a little bit better, it’s available. It’s there for us.

    Finally, continuing education. We’re in a very fast-moving medical world. So what they offer us in continuing education is just phenomenal.

    Where did you grow up?

    I grew up in Hollywood, Florida. I started my prerequisites at Broward Community College and didn’t know anyone except a cousin in Georgia, but I had always heard Georgia was a beautiful place.

    In high school I was the recipient of a junior scholarship. It was out of financial need, and it was for dental hygiene because I had six years as an oral surgical and dental assistant prior to becoming a nurse.

    Even though I had received a scholarship, I stood up and I said, “Please give this to someone who is going into dental hygiene, I’ve just decided I’m going to go into nursing and become a nurse.” I gave up the scholarship to someone who could definitely go forth and use it for their dental hygiene career.

    Are you married? Do you have children?

    I do not have children, but I rented about a thousand of them. I was in pediatrics for 12 years. It was an absolute joy. I did not have children by choice. I am married to my absolutely most adorable best friend.

    What is your favorite hobby?

    It is my art and being outside. I love to create unique pieces. And Mother Nature is one of my greatest past times. We live on a creek and I just love the hummingbird migration time. I feed the birds, the rabbits, and the deer; we had baby warblers, cardinals and wrens this year. I love watching them making their homes and nest. And then they have the babies right there.

    Is there a book you recently read or a movie you saw that you would recommend?

    Yes, l very much like the David Baldacci series. I just loved the Camel Club (a trilogy). And I was so excited about the new Men in Black movie that came out. But that’s not the one I would recommend. I would recommend Avatar, for its creativity. And I’m an old movie buff. Gunsmoke is one of my favorites.

    Any additional comments?

    I’m in a place in my career of combining business and medicine. I guess that dreams do come true. I worked very, very hard to get here and I am honored to be with a company like Aetna.

    Click here to learn how you can be featured in one of our Case Manager Profiles.

    Meet Health Coach Alexis Koutlas: Natural Progression from Nurse to Case Manager to Coach

    February 18th, 2013 by Cheryl Miller

    This month’s inside look at a health coach, the choices she made on the road to success, and the challenges ahead.

    Alexis Koutlas, BSN, CCM, CHC, specializing in women’s, children’s and health professionals’ wellness

    HIN: Tell us a little about yourself and your credentials.

    (Alexis Koutlas) After graduating with my BSN, I started my professional career in women’s and children’s services. Over time I shifted roles from the bedside to referral and case management for high-risk obstetric patients and pre-term infants. Wanting to understand how these children progressed and what their needs were, I then transitioned to the outpatient arena in pediatric medicine. Once there, my interest led me to preventative medicine, which led me to the discovery of health coaching. Since receiving my Certified Health and Wellness Coaching certification from Vera Whole Health, I look at my nursing role as promoting and supporting wellness, rather than treating just the illness. I’m passionate about supporting children and colleagues, helping them to engage in their own health and well-being, and learning to be the best selves they can be.

    What was your first job out of college and how did you get into case management?

    Out of school I jumpstarted my career in a neonatal intensive care unit (ICU). What a fantastic opportunity that was! I worked in an academic care facility and had the opportunity to work with some very well-respected practitioners. To keep up with changes in the environment of care, the medical leadership created a position for a case manager, which I accepted, working directly for the physicians who were part of the Division of Perinatal and Neonatal Medicine. It wasn’t a traditional case management position; actually, our approach was quite unique. Rather than try and cut length of stay, we looked at the positives for increasing the length of stay of the mom, to decrease the infant’s length of stay and morbidities that occur from prematurity. There was no certification for this at the time. Working together for the best outcome for high-risk obstetric patients, we were able to expand the role to include referral management, supporting patients across the Pacific Northwest, Montana and Alaska.

    When did you decide you wanted to go into health coaching?

    The transition from treating illness to preventing illness was an entirely new concept that I discovered as I moved into the outpatient arena. Along with focusing on patient wellness, the care environment supports nurses’ own self-care. Better work hours and shorter shifts allow nurses to balance a personal life. My newfound schedule allowed me to engage with my own fitness and health regimens. And along the way, I met such fantastic, energetic experts who see and support the movement of wellness, and I am excited to return that gift to others.

    How has your medical and case management background impacted your career as a health coach?

    Understanding the physiologic ramifications (medicine) of the lack of wellness — the mental, physical and emotional components — is like the slab of foundation for a home. Understanding the financial ramifications and the necessity for conscious spending (case management) is that budget we maintain to build that home. Health coaching, however, is the covering; the roof, walls, windows and doors. If the roof leaks, the budget will be affected by the cost of repairs and your foundation will be destroyed from mold. Health coaching is the natural progression. Having a background in disease management enables me to help clients explore their own processes and circumstances with a deeper level of understanding.

    In brief, describe your organization.

    I’m an independent practitioner and specialize in two dynamic groups.

    • The first: families affected by pediatric obesity. Pediatric obesity is not just a child’s problem. It’s a family’s problem, and working with getting these children to engage in their health takes more than working with them independently.
    • My second area of focus: healthcare professionals. I work to get them to explore their own health needs and their role and responsibility as representatives of health, not just disease management.

    What are two or three important concepts or rules that you follow in health coaching?

    • Never have a road map for your client.
    • The client has the answers, the client has the answers, the client has the answers. My job is to coach them, weed through all the mush to get to the answers that only they have and know are best for them.
    • I cannot successfully coach someone else if I am not working to care for myself.

    What is the single most successful thing that your organization is doing now?

    Health coaching is new. Independent practice is newer. The greatest most effective thing I can do at this time is promote the movement, help people understand why it’s important, and get them to engage in it in a different way. This is trailblazing and so with the weed eater in hand, I keep moving forward.

    Do you see a trend or path that you have to lock onto for 2013?
    Recognition of the wellness movement. On the West Coast, we are last to catch up to other parts of the country. Defining wellness, making it a household term, is progress in itself. Taking it into western medicine and proving its worth is monumental and will continue to be a work in progress backed by data acquired over time. Unfortunately, automated health coaching set us back from this goal. Two steps forward, one step back.

    What do you mean by automated health coaching?

    Automated, or scripted coaching from computer generated scripts. For example, you have this diagnosis, and the script encourages such and such questions. Hospitals have purchased the automated heath coaching for their employees. All the employee has to do is click here that they are getting their BP checked, and click there that they walked three times this week. For this, they receive a nominal bonus. The incentive is the bonus. Many employees participate. Many employess punch the buttons. Many employees do not make the changes that are necessary. I had the fortunate opportunity to have an informational interview with the person who has championed getting this service into a local hospital facility for their employees. She agrees, the true success behind this method will be to engage employees without significant issues or the ‘low hanging fruit’. The fact is, nothing replaces one-on-one personal coaching. But for right now, it isn’t a covered benefit, and if it was, would people value it the same way? I liken it to paying for a fitness trainer. The fact is, it’s personal service. It’s expensive. But when I pay for it, I am engaged with it. If someone else was paying the bill, I may show up, but would I engage?

    What is the most satisfying thing about being a health coach? How is it different from case management?

    As a coach, when the client discovers their sense of direction, that sense of self, that “aha” moment that is life changing, it reaffirms what I love about healthcare. It supports the notion of supporting health and allows the patient to design, dream and discover for themselves. Case management sets up a series of rules, set by a governing body with a focus on finances and limits the patient’s ability to be independent in their choices for improving their care. Although the goals are similar, i.e. patients who are not dependent upon the healthcare system, the methods to acquire the goals are in opposition.

    What is the greatest challenge of health coaching and how are you working to overcome this challenge?

    Understanding and engagement. People are naturally skeptical. They are unsure what they are getting with health coaching. It’s new. For those who have had exposure, they get it. They understand they have been beneficiaries of the inherited ‘wealth of health’ through their hard work. For others, it is an unknown. The most effective health coaching happens when the person is invested. Not only emotionally, but financially. Since this is not a covered service by insurance, it requires private funding. That can be costly, but the return on the investment is ten-fold. In short, people NEED to pay for the service, for their own sake, to reach success and stay motivated. But by the same token, it’s a cost that many are unwilling to pay if they are unsure of what it can do for them.

    What is the single most effective workflow, process, tool or form health coaches are using today?

    • For the client: Getting them to a state of awareness at the beginning of each meeting. We so often go through our days as robots. We eat because it’s time to eat. We make lists and try and accomplish the items on the list. But are we ‘present’ with ourselves? Getting the client to ‘be’ for the coaching time allows them to process on a deeper level.
    • Processes for me as a coach: Working with clients to clearly define, describe, dream and design their goals and utilize both motivational interviewing as well as appreciative inquiry as tools to help clients separate out the mush and reach their own personal levels of success.

    Where did you grow up?

    I grew up in a little town just north of Seattle, Washington.

    What college did you attend? Is there a moment from that time that stands out?

    I attended college at Marquette University in Milwaukee, Wisconsin. It’s hard to pick one moment that stands out because there are so many memorable events in college. However, if I have to pick one, I’ll choose the moment I arrived at the school of nursing. Growing up in the country, arriving at an inner city university was culture shock. Add to that the moment when I sat in nursing orientation and heard the dean speak. “Look to your left and look to your right. One of you won’t be here when you graduate.” I remember thinking – “what am I going to do to be here? What qualities do I have to help me get through this?”

    Are you married? Do you have children?

    Unfortunately I have never married and do not have children. I believe that this is in part one of the reasons I have always enjoyed working in pediatric medicine. I like to say “even when I’m in a bad mood, somewhere during the day, some child will make me smile.”

    What is your favorite hobby and how did it develop in your life?

    Designing my own fitness routines and attending fitness classes with my favorite trainers. After years of being a couch potato, when I took stock in my own health, I realized that I needed to make changes to not only be a healthier person, but a better person, a happier person, a better employee and health coach. Throughout my learning, I found great trainers, and have met great friends. I’ve learned what motivates me and what keeps me engaged. I now look forward to creating my workouts and challenges.

    Is there a book you recently read or movie you saw that you would recommend?

    Ok, this is not a good movie. Not noteworthy in the sense that anyone with great intellect would feel compelled to watch. But for me, I loved “Step Up” – the original with Channing Tatum. Why? Pure and simple, the dance. I am both inspired and enamored with the physical strength, endurance and flexibility of dancers. To me, their movement is its own form of expressive art. I’ve worked with dancers in some of my personal training modalities. Those experiences have led me to appreciate the true talent and physical discipline that each and every move requires. However, buyer beware, this really is a B movie at best. If you choose to enjoy it, think about it from the perspective I’ve shared and see if it doesn’t improve the enjoyment factor.

    Click here to learn how you can be featured in one of our Case Manager Profiles.

    Meet Healthcare Case Manager Michelle Guinane: Empowering Others to Take Control of their Health

    February 5th, 2013 by Cheryl Miller

    This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

    Michelle Guinane, RN, CCM, registered nurse case manager in Patient Management Division at Aetna.

    HIN: Tell us a little about yourself and your credentials.

    Michelle Guinane: I am a registered nurse (RN) case manager for a dedicated unit at Aetna. I have been a nurse for 16 years, working in the hospital setting for 10 of those years and specializing in cardiology telemetry/ICU. I also worked in the ER, orthopedics and rehab.

    What was your first job out of college and how did you get into case management?

    I attended Hahnemann University/Drexel University and was offered a position to stay on board at their hospital, but declined due to the city wage tax and the parking fees. Instead, I accepted a full-time home healthcare (HHC) position at Professional Nursing in Valley Forge, PA, where I had been working throughout school to help pay my tuition. I loved working there. It was my first lesson in making decisions independently and helping families to prioritize and manage their families’ care at home. I enjoyed the focus on the patient and the families.

    Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

    Several years after my transition to the hospital, one of the families that I had worked with for several years in HHC called the floor I was working on and explained that a quadriplegic patient I had cared for, the patriarch of the family, had been on hospice with a different agency and was dying. They asked me if I could be there. After my shift I went to their home and was able to offer support to him and his family. He died shortly afterward. I felt very honored and blessed to be part of such a private family time, and felt very much a part of that family.

    In brief, describe your organization.

    I work in the Dedicated Unit for case management at Aetna Healthcare Insurance, a Patient Management division. I outreach to our insured patients to assist them with educational needs for complex disease management, and help them navigate their insurance plan and benefits. I do this prior to, and following surgery to ensure that they feel prepared for the procedure. Following surgery and/or hospitalization, I also support them all the way through their treatment plan until they feel knowledgeable and confident managing their healthcare. Based on the patient’s diagnosis, I provide them with resources, through Aetna, their employer, and the community, in order to offer them financial, social, emotional and educational support.

    What are two or three important concepts or rules that you follow in case management?

    • Listen to the patient and the family for identified gaps in care, knowledge deficits, and opportunities to provide them with education and resources. Patients know when you are really listening, and this will help you establish an initial trust quickly so you can help them navigate their benefits and treatment plans and assist with any needed coping mechanisms.
    • Collaboration of care amongst the patient, providers and caretakers is essential in moving patients toward wellness, decreasing miscommunications and helping patients feel confident in managing their healthcare.
    • Let the patient and family know they are never alone on their healthcare journey. In addition to the support and education I provide, there are many wonderful community resources I can utilize to get members motivated and educated. It’s important that they realize that they are part of a bigger community of patients so they do not feel isolated with their diagnosis.

    What is the single most successful thing that your organization is doing now?

    In addition to multiple fundraising efforts for hurricane victims, I would say that Aetna’s focus is on healthcare reform laws.

    Do you see a trend or path that you have to lock onto for 2013?

    Healthcare reform.

    What is the most satisfying thing about being a case manager?

    Having the opportunity to develop a trusting relationship with patients, and being witness to their progression from perhaps fear of their initial diagnosis to developing coping mechanisms and learning about their disease process. It is very rewarding to hear a patient say that they no longer need case management because they feel empowered, to see that they are no longer afraid to ask important questions, engage in resources or have open discussions with family and providers.

    What is the greatest challenge of case management and how are you working to overcome this challenge?

    The economy has taken a toll on many patients’ job statuses, and their goal is to find financial resources, and senior and community centers that can help them to feel part of the community and not isolated. Helping patients to do this, as well as assess their treatment plan progress and help them communicate effectively with providers and family is my focus as the case manager. For example, if a patient is suffering with a particular disease, and I can help them engage in a low-impact exercise regime at a gym, senior center or community center, this helps them increase their mobility, feel less pain and increase their social interaction.

    In addition to financial barriers, sometimes it is just a matter of helping the member to overcome their personal fears of their disease, let them know they have support and help them find the courage and confidence to manage their healthcare.

    What is the single most effective workflow, process, tool or form case managers are using today?

    We use very specific workflows at Aetna – all policies and procedures are well established.

    Where did you grow up?

    I grew up in Hatfield, PA.

    What college did you attend? Is there a moment from that time that stands out?

    I attended Penn State University for prerequirements to nursing and then transitioned to Hahnemann University (which is part of the Drexel Network) in Philadelphia, PA., where I had a great nursing experience. Hahnemann is a teaching hospital, and you are not allowed to just ask questions; you are expected to engage in dialogue with all areas of the medical team. It taught me to have confidence in my nursing judgment. I had wonderful opportunities to meet and work with some of the country’s top cardiology experts and nurses, and I cherish that time. I felt very well prepared for anything. Hahnemann is a large teaching hospital but very supportive and progressive.

    Are you married? Do you have children?

    I have been married for 16 years and have two active children: my daughter is 11 and is avid in running, track, volleyball and basketball. My son is eight years old and plays baseball.

    What is your favorite hobby and how did it develop in your life?

    Cooking is my second passion. My husband is a chef and a large part of our family time is spent cooking and entertaining. Had I not been a nurse I would be running a bed and breakfast somewhere.

    Is there a book you recently read or movie you saw that you would recommend?

    Reading is my other second passion. My favorite book of all time is non-medical, but inspiring: The Power of One, by Bryce Courtenay.

    Click here to learn how you can be featured in one of our Case Manager Profiles.

    Q&A: Integrated Health Coaching Brightens Total Healthcare Picture of Population

    November 21st, 2012 by Jessica Fornarotto

    To determine the coachee’s values, the health coach listens to achieve empathy and understanding, which demands that they have a sense of an individual value, says Kelly Merriman, vice president of service delivery at HealthFitness.

    Prior to their presentations during a September webinar on Integrated Health Coaching: The Next Generation in Health Behavior Change Management, Merriman and Dr. Dennis Richling, chief medical and wellness officer at HealthFitness, discussed HealthFitness’ transition to a population health management focus, why HealthFitness’ coaches target the chronic disease population and a new coaching tool called appreciative inquiry.

    HIN: How has HealthFitness’ shift from a disease management to a population health management focus meshed with the industry’s post-reform models of care, for instance the patient-centered medical home (PCMH) and the accountable care organization (ACO)?

    (Dr. Dennis Richling): HealthFitness has had a population health management focus for many years and we see that many of the same principals that we use in our approach are included in ACOs and in medical home models.

    Recently, we took a new look at disease management, which traditionally has been a stand-alone service, largely focused on patient self-care issues separate from lifestyle coaching interventions. In our new model, health behaviors across the entire risk continuum are dealt with in a person-centric way, rather than a disease-centered approach. That of course aligns with some of the principles of the post-reform models of care, like the medical home, and even to some degree with ACOs, which are attempting to be responsible for the total healthcare picture of a population.

    HIN: In your company’s three-tiered coaching across the continuum approach, where do most of the coaching candidates fall?

    (Dr. Dennis Richling): In every population you find different numbers, but in a typical employer, we see that the greatest opportunity for coaching is in those individuals who have behaviors that can lead to chronic disease. A good example of an ideal candidate for our coaching program is a 40-year-old manager working 50 hours a week. His blood pressure isn’t high, his cholesterol is slightly elevated and he’s a little overweight. He doesn’t exercise regularly and while he tries to watch his fats, he isn’t eating the most healthy diet because he hasn’t figured out how to balance his work schedule and his family life, and being 40. He’s also at risk for chronic disease. If he adopts more healthy behaviors, he can avoid developing a chronic disease.

    Then there are those who already have a chronic disease like diabetes or coronary artery disease. This is about 10-20 percent of a population, depending on the population we’re looking at. Instead of putting all of them into nurse coaching, like traditional disease management, we determine through claims and a short assessment if the disease is well managed. In our experience, about three-quarters of those with chronic disease are taking their medicines and managing their diseases relatively well, though, they still need help with the underlying lifestyle issues that led to the chronic disease.

    Those individuals are matched with an advanced practice coach (APC) who understands their underlying chronic disease issues, but will work with them to achieve goals that they want to work on, like losing weight or exercising regularly. By far the smallest group is those with the newly diagnosed or uncontrolled chronic disease. We match them with nurse coaches who can most effectively work with their self-management approaches, with making sure that they follow their medication and care plans that the physicians have prescribed.

    HIN: In tailoring a coaching program to the individual, how does a coach determine the coachee’s values?

    (Kelly Merriman): We call it ‘listening until you don’t exist.’ Most people listen to get information or because they enjoy the process of exchanging perspectives. Our coaches listen to achieve empathy and understanding, which demands that they have a sense of an individual value. For example, Michelle is 46 years old and is significantly overweight. And because of her weight, she’s a pre-diabetic. She told her coach that she was ready to make a change. She knew her weight wasn’t only impacting her health, but also her self-esteem. Michelle’s coach listened and learned that she took pride in being a pillar of support for family and friends, that ‘never let them see you sweat’ mentality, which meant she was holding in her fears of being overwhelmed at times.

    Imagine if a coach reflected back thoughtfully and said, “I’m hearing, Michelle, that you take pride in caring for others, that you value being competent and having others rely on you for support. And sometimes when things get to be a little too much, you overlook your own health.” Once a coach finds those values, they’ve got something to work with to promote hope and inspiration. It’s what we call motivation.

    HIN: Could you provide some details on appreciative inquiry and perhaps describe a scenario in which a coach might employ this tool?

    (Kelly Merriman): All too often when people want to change a behavior, they tend to focus on all the negatives. All the attention goes to focusing on what’s broken. That focus can hold a participant back from achieving their goal. Our coaches use appreciative inquiry to focus on the participant’s strengths instead. The appreciative inquiry approach deliberately seeks to discover that person’s exceptionality, through their unique gifts, strengths and qualities. We listen with intent to appreciate who they are during the early coaching interactions and then envision how they want their life to be.

    Appreciative inquiry has low resistance as an approach to change because it builds upon the person’s positive core, the things that they already have going for them. It assumes that tapping into their positive experiences and strengths are useful in discovering their intrinsic motivation to change and development. This immediately shows the coach and the participant that they have faith in the ability to make a positive change.

    As an example, let’s look at Michelle again. We want to appreciate what she’s got going for her and use that to help her to envision what her future may be. Michelle is overweight, pre-diabetic and feeling overwhelmed. Her coach learned that she’s committed to her health, takes pride in being a pillar of support for her family and friends and is organized and creative. Instead of focusing immediately on fixing what’s broken, that she eats too much between meals and doesn’t exercise enough, her coach focuses on envisioning Michelle’s idea of health, one that honors her strengths and her values. In this case, Michelle’s vision of health may be using her creativity and strengths of purpose to take care of her own self as well as the people she loves. She’ll make healthy choices, will see the results, and have the freedom to live the life she wants.

    Healthcare 80/20 Law Saves Consumers Over $1 Billion

    June 25th, 2012 by Cheryl Miller

    Consumers should check their mailboxes this August

    Insurance policy holders just might have some extra spending money this summer.

    According to the HHS, insurance companies that don’t meet the 80/20 healthcare rule of spending, which requires them to spend at least 80 percent of consumers’ premium dollars on medical care and quality improvement, and the remainder on administrative costs, must provide their policyholders a rebate for as much as $151 no later than Aug. 1, 2012. Consumers can expect a notice from their insurance company informing them of the 80/20 rule, whether their company met the standard, and, if not, how much of the difference between what the insurer did or did not spend on medical care and quality improvement will be returned to them.

    Eligible healthcare organizations have already been reimbursed by the government for adopting EHRs for meaningful use. In fact, the CMS met its goal of getting 100,000 organizations on board with its EHR incentive program three months earlier than planned: more than 110,000 eligible healthcare professionals and over 2,400 eligible hospitals have received over $5.7 billion in payments as of the end of May. The end of 2012 was the original target goal. Officials hope the increasing use of EHRs will provide better patient care, cut down on paperwork, and eliminate duplicate screenings and tests.

    Pharmacists could help manage the country’s healthcare costs if the results of a new study from Walgreens prove fruitful. Walgreens pharmacists trained over 4,500 patients starting self-injectable diabetes medication for the first time on appropriate injection technique, side effect management and the importance of adherence to therapy. Pharmacists also provided a follow-up assessment at the patients’ next refill meeting. Initial results showed that patients who received two counseling sessions with a pharmacist were 24 percent more adherent after 90 days and had an additional eight days of therapy compared to a usual care control group.

    Employers, too, are looking for ways to keep their costs down, with employee healthcare plans a prime target. A study from J.D. Power and Associates reveals that almost 50 percent of employers might pursue alternate methods of employee healthcare coverage, including defined contributions, vouchers and exchange purchasing. A smaller percentage of fully insured and self-funded employers said they might discontinue sponsoring employee coverage completely. Details in this issue.

    And lastly, we have a new survey on asthma management. Asthma drives a lot of healthcare utilization — half a million hospitalizations and nearly 2 million emergency department visits in 2009 alone. We invite you to share how your organization is managing asthma in the populations you serve by July 27, 2012. In return, we’ll e-mail you an executive summary of trends in asthma management.

    All this and more in this week’s Healthcare Business Weekly Update.