Disease Management

The AveCare Disease Management module provides a step-by-step “best practices” approach to managing and educating members who have the following conditions: 

  • Asthma
  • Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Coronary Artery Disease
  • Congestive Heart Failure
  • Hypertension

Candidate Identification

In AveCare, the identification of potential candidates for disease management can occur in multiple ways:

  • During the utilization review process, candidates can be identified based on a “trigger list” of diagnoses,
  • Candidates can self-refer or be referred by physicians or family members, or
  • If client claims data is available, candidates can be identified through the system.

In the latter circumstance, identification is done automatically at the time the medical and pharmacy claims are imported into the system. Based on CPT codes, ICD9 codes and certain internal algorithms, disease management candidates can be automatically placed into “group” queues to be reviewed. Users then have online access to candidates’ medical and pharmacy claims to assist them in determining if disease management should be performed and in monitoring ongoing claims expense for the patient.
Once a patient is identified as a candidate for disease management, the AveCare system has the online tools necessary both to assess the patient’s clinical and functional status and to establish a plan of care. The system contains an automated “fill-in-the-blanks” health risk assessment, automated “fill-in-the-blanks” disease-specific assessments for each managed disease, and an automated “fill-in-the-blanks” care plan to facilitate consistency in the identification and management of health issues.

Automated Assessments

The automated health risk assessment contains questions related to the following categories of information:

  • Family Medical History
  • Patient Medical History, including
    • Known diagnoses
    • Medications/prescriptions
    • Allergies/allergic reactions
    • Immunizations
    • Diagnostic tests and laboratory information (recent x-rays, lab results)
  • Lifestyle, including
    • Tobacco use
    • Alcohol use
    • Stress and well-being
    • Nutrition
    • Exercise
    • Safety issues
    • Work and education

The disease-specific assessment, which is automatically populated with relevant information from the health risk assessment, then asks additional questions specific to the particular disease, including current symptoms, current efforts to manage the disease, etc.
Since both the health risk assessment and disease-specific assessments are automated, the evaluation process is not only more efficient for the capturing of critical health information, but also definitively consistent from patient to patient.

Automated Care Plan

The system also provides an automated care plan function, which provides the user with the following information/capabilities:

  • Family medical history (populated from the health risk assessment)
  • Patient medical history (populated from the health risk assessment)
  • Chart function, which is a specific area for the entry and maintenance of physical stats such as height, weight, blood pressure and medications (populated, as applicable, from the health risk assessment)
  • Problem, Intervention, Goals and Outcomes section, in which the user can identify problems to be addressed, interventions that will address the problems, goals to be achieved relative to management of the problem, and outcomes of the intervention.

With regard to the latter section, the system provides disease-specific templates that identify typical problems associated with a disease, along with suggested interventions and goals to facilitate consistency with regard to the handling of similar diseases/conditions.

In order to facilitate the assessment process and development of a care plan, responses to questions in the initial health risk assessment auto-populate similar fields in the disease specific assessments and care plan, so that there is no redundant data entry. Also, users can stop at any time during the assessment/care plan process, save their work, and return to where they left off at a later time.

Task Management

Through its queue module, AveCare facilitates the establishment of follow-up dates and tasks for a patient based on the needs dictated by the care plan. At the time of assigning the follow-up date and task, the user can also add notes indicating in greater detail what is to be accomplished during the follow-up. Each user can sort his/her queue entries based on follow-up dates or use a date-range filter to view only today’s or near-term follow-ups, which is typically done at the start of each day. Reports are also available to supervisors/managers indicating pending follow-ups and follow-up dates that have passed without activity.

Patient Information

Because the utilization review and disease management functions are integrated in the AveCare system, disease managers have ready access to utilization information and any other system-related activity for a particular patient. Also, the system contains a “claims view” screen in which claims data is stored and updated for user review.

The claims view screen provides disease managers with a significant tool for determining health status and for monitoring patient compliance. Providing access to both medical and pharmacy claims on a patient, this screen can be easily accessed from any of the key system modules.

Also, the AveCare system contains a “community resource” function which maintains a list of nationally recognized community resources. Upon referral by a nurse to a community service, the system will store the referral date, referral type, who made the referral and free form notes about the patient. The system also allows the user to add new local resources that are not already in the system’s database. Reports can be produced on community referrals for patient or group activity.

Educational Sessions

Once management and educational needs have been assessed, AveCare has online educational sessions that can be customized to the patient. There are sessions for each of the diseases listed above. As an example, the following is a list of the online educational sessions for asthma:

  • Intro to Asthma
  • Diagnostic Testing
  • Asthma Medications
  • Zone Management Plan
  • Inhalers and Spacers
  • Risk Factor Triggers
  • Nutrition
  • Assessment Educations Needs
  • Exercise
  • Travel
  • Support for the Caregiver
  • Health Lifestyles
  • When to Contact MD

Reporting

With regard to program monitoring and tracking and reporting, the system can generate reports which allow for both internal (operational) and external (client) monitoring. The reports track activity on behalf of each patient, (e.g., initial contact, whether the patient agrees to participate in the program, whether educational materials have been sent and educational sessions conducted, etc.) These reports ensure not only that all candidates are evaluated but also that all participants are managed on a timely basis. Moreover, they provide an overall summary of program effectiveness in terms of candidate identification, program participation, etc.

Letters

Customized letters regarding Disease Management can be produced directly from the application so that timely notification can be rendered. The system provides a historical log of all letters sent and can also track the mailing of educational materials to the patient.

Additional Functionality

The following system-wide functionality also supports the disease management function:

  • The contact screen allows the reviewer to track all the outgoing and incoming contacts made on a patient, along with the outcome of each contact.  Activity reports can be produced to show a complete record of contacts for a patient.
  • The queue screen provides a To Do list with automated follow-up notification for reviewers, supervisors and physicians to manage their workflow. The screen tracks each phase of disease management with follow-up dates to insure compliance with internal timeframes. Management can track the case load and turnaround times of each reviewer by accessing the Queue Screen or by running reports. Supervisors and managers can also transfer cases from one reviewer to another.
  • The note screen stores free-form and client-specific notes related to disease management services. The application tracks notes by category type, date written and reviewer; and it has a “pick list” option that will automatically insert selected wording that a client has created based on sentences and phrases commonly used.
  • The billable hours screen, accessible from any system module, provides each user a single location for the posting and tracking of billable time/activities.
  • The physician and facility screens provide ready access to key physician and facility information in support of utilization review activity, including provider demographics and network affiliations.