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Technology-driven interactive care management identifies and resolves more clinical issues than a claims-based alerting system.

Iver A Juster
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Abstract

Due to patient or physician factors, people with chronic diseases frequently do not receive evidence-based care. While a physician-directed claims-based alerting system targeting gaps in care was previously shown to increase resolution of specific clinical issues, many apparently relevant issues remained unresolved. The purpose of this research was to demonstrate that adding member interaction with a nurse to a physician alerting system can uncover additional care gaps beyond those identified by a claims, prescription, and lab results-based alerting system, and increase successful resolution of alerts by communicating care gaps to members. An opt-in nurse-managed pilot program focusing on identification and resolution of specific clinical issues was implemented for 205,463 members of self-insured health plans that had been utilizing the claims-based physician alerting system. Specific clinical issues identified by the claims-based system were communicated to both program enrollees and physicians, and new clinical issues were identified based on nurse-directed participant feedback. Participants were encouraged to discuss issues with their physicians. Issue resolution rates were tracked using subsequent claims, pharmacy, and lab data. At 1 year, we studied the rate of new clinical issue identification and compared the program's resolution rate of claims-identifiable issues to that of non-enrollees. While program participants accounted for 0.65% of total member-months in the pilot year, they triggered 4.82% (644) of the population's claims-based clinical alerts, and an additional 514 alerts from data based on participant-supplied data--80.8% more than claims/pharmacy/lab-generated alerts. Of the participants' claims-based alerts, 207 (32.1%) showed claims/lab evidence of successful resolution, compared with 3,380 of 12,714 (26.6%) for non-participants, a 20.9% increase in resolutions (chi2 = 9.8, p < 0.01). Care management technology complemented by a nurse-directed interactive program increased the rate of identification of clinical issues compared to claims alerts alone. Use of this program to communicate specific issues to both patients and physicians significantly increased the rate of issue resolution.

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Decision Support Systems, ClinicalDisease ManagementHumansInsurance Claim ReportingInterdisciplinary CommunicationManaged Care ProgramsNurse's RolePatient ParticipationPhysician's RoleJournal Article

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Iver A Juster. 2005. Technology-driven interactive care management identifies and resolves more clinical issues than a claims-based alerting system.. https://doi.org/10.1089/dis.2005.8.188

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