Beauty Health for Life

Care management planning

Hot off the heels of this cinematic debut on how NOT to conduct care management comes this handy Alliance of Community Health Plans 29 page handbook review on how to do it right.  Some of the experienced members of the Alliance shared insights on successful population health approaches, data on the "return on investment" and how to deal with the physicians.

But, say the Hardball-inspired Disease Management Care Blog readers, "tell us something we dont already know." 

The DMCB found three useful nuggets of information:

1. There is no firm rule on the operational balance between central administration and peripheral distribution.  Some of the Plans hire and oversee the care management nurses while others pay their network primary care sites to hire their own nurses.  If the practices employ the nurses, they are free to let the managers see patients on an all-payer basis.

2. Care management caseloads vary from 35 to 150 persons and the enrollee to nurse ratio ranges from one full time nurse to 5000 to 14,000 commercial members. If less than 5000 Plan members are assigned to a primary care site, care managers split their time among multiple sites.  As Plan members are further diluted or distributed through a network, there is greater reliance on remote telephonic communication and coaching. 

3. Reduced costs?  Group Health, Fallon and Security Health plan say they saved over $2.5 million, $2.3 million, and $1 million, respectively. Tufts Health Plan says they saved $1.90 for every dollar spent.

Other points known but worth repeating:

Features of successful care management include appropriate patient selection, person-to-person outreach, credentialed professionals, teaming, coaching on self-management, family involvement and access to community-based programs.

Embedding care managers in the primary care sites is worthwhile not only because face-to-face patient care has more of an impact, but because the physicians will benefit from the consultations, participation in "huddles" and discussion of the treatment plans. That also leads to a greater level of trust between the docs and the nurses.

Theres better buy-in if the care managers are viewed by enrollees as an extension of the physicians, not the sponsoring insurers. 

Technology is important: effective care managers are made more effective by electronic records, telemonitoring, decision support, work-flow aids and video/mobile communication.

 The backbone of care management is made up of generalist nurses who are simultaneously comfortable with multiple conditions such as, for example COPD, mental illness and diabetes.  That being said, there is a role for focused nurse support for patients with special needs, such as hospice, transplant or bariatric surgery.

An abundance of data support is only the beginning because the reports will need to be tailored to the physicians clinical needs  and communication perences.  They also have to be paired with regular meetings that promote best practices and solicit feedback.

When care management is first rolled out, physicians will first suspect this is another managed care ruse, assume its a fast track to prior authorization or try to "downjob" clinical duties to the nurses that are outside of their scope of practice.  It will take many months and much collaboration to sort out turf issues, control, office space, and offering care management to some but not all patients.

You know, how sometimes, when you discover something no one else knows about, you get all excited, but a little hesitant to share your newfound knowledge, because it wouldn’t be JUST YOURS anymore?

I used to feel that way about music. My friend H. introduced me to Jeff Buckley in 1995, my freshman year of college. His Grace album became a touchstone of our existence, with the final track, a cover of Leonard Cohen’s Hallelujah, as its crowning achievement. And even though H. shared Buckley with me, I was hesitant to pass him on to anyone else. I felt like it would take the specialness away.

Well, here’s the thing. If something’s really good, odds are people will find out about it anyway. Buckley drowned in 1997. In 2002, The West Wing used Hallelujah for a death scene. Two years later, it popped up on the season finale of The O.C. Now, Simon Cowell counts it among his favorite tunes, and it appears on American Idol every other second.

I’m okay with this. Because, I figure, the mass acceptance of Hallelujah will nudge Buckley toward … man, I hate the word “immortality” in this context, but I can’t think of another one … so, immortality. It’s good for him. It’s good for his family. It’s good for music.

Subsequently, I resolve to share things that are good. It makes no sense keeping them to myself. And Moosewood’s Simple Suppers may be my new favorite thing on Earth, never mind just the Cookbook category.

I’m trying to experiment with a wider range of recipe tomes, so I’m not so reliant on my favorite sources. A quick trip to the library yielded Simple Suppers, which has now produced three smashing dishes. I go into the other two in detail at Serious Eats. White Bean and Mushroom Ragout is here. Potato Salad with White and Green Beans can be found at the top of this post. They are both drool-worthy.

The latest dish is Lemony Couscous with Chickpeas. It’s a delicious simple grain salad you can customize to your heart’s content, because it will still retain its essential, uh, lemony … couscousy … chickpeaness. Yeah. One batch gave us food for DAYS, and we served it both hot and cold.

So readers, what are your favorite little-knowns? Let us know, and maybe we can make them big-knowns. It could be a good thing.

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If this recipe seems enticing, these will tempt your pants off:

• Breakfast Couscous Custard with Peaches
• Gazpacho Pasta Salad
• Israeli Couscous Salad

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Lemony Couscous with Chickpeas
Makes at least 8 side servings.
Adapted from Moosewood’s Simple Suppers.


1 1/2 cups plain or spinach couscous
1/2 teaspoon salt
2 1/2 cups boiling water
2 lemons
3 tablespoons olive oil
1 14-ounce can chickpeas, rinsed and drained
1 cup chopped black olives (about 20 large)
1/8 cup slivered almonds, toasted

Optional (but use at least one):
2 tablespoons dill, minced
1/2 cup parsley, chopped
1/2 cup scallions, chopped
1/2 cup mint, chopped

1) In a medium bowl, combine couscous and salt. Pour water on top. Cover. Walk away for ten minutes. Water should be gone and couscous fluffy when time is up.

2) Meanwhile, zest both lemons into a smaller bowl. Then juice them to get 1/4 cup, and pour that into the same bowl. Add olive oil. Whisk together.

3) Fluff couscous. Add chickpeas, olives, dressing, and herbs. Stir thoroughly to combine. Salt and pepper to taste if desired (but you might not need it). Sprinkle with almonds. Serve hot or cold.

Approximate Calories, Fat, Fiber, Protein, and Price Per Serving
With parsley and scallions: 263 calories, 8.1 g fat, 4.6 g fiber, 7.5 g protein, $0.80

Calculations
Note: I used parsley and scallions for my dish. Those are being factored in here.
1 1/2 cups plain couscous: 976 calories, 1.6 g fat, 13 g fiber, 33.1 g protein, $2.28
1/2 teaspoon salt: negligible calories, fat, fiber, and protein, $0.01
2 1/2 cups boiling water: negligible calories, fat, fiber, and protein, FREE
2 lemons (zest & 1/4 cup juice): 16 calories, 0 g fat, 0.3 g fiber, 0.2 g protein, $0.66
3 tablespoons olive oil: 358 calories, 40.5 g fat, 0 g fiber, 0 g protein, $0.36
1 14-ounce can chickpeas, rinsed and drained: 500 calories, 4.6 g fat, 18.5 g fiber, 20.8 g protein, $0.66
1 cup chopped black olives (about 20 large): 125 calories, 10 g fat, 0 g fiber, 0 g protein, $0.91
1/8 cup slivered almonds, toasted: 85 calories, 7.5 g fat, 1.5 g fiber, 2.9 g protein, $0.23
1/2 cup parsley, chopped: 11 calories, 0.2 g fat, 1 g fiber, 0.9 g protein, $0.99
1/2 cup scallions, chopped: 32 calories, 0.2 g fat, 2.6 g fiber, 1.8 g protein, $0.33
TOTAL: 2103 calories, 64.6 g fat, 36.9 g fiber, 59.7 g protein, $6.43
PER SERVING (TOTAL/8): 263 calories, 8.1 g fat, 4.6 g fiber, 7.5 g protein, $0.80