The goal of our Primary Care and Emergency Room (ER) Care Management Program is to improve the quality and affordability of primary care, emergent, urgent and chronic care by developing programs, tools and initiatives and working collaboratively with you.
We consider primary care to include patient care delivered by internists, family practitioners and pediatricians. We are also focused on care provided in urgent and emergent care settings, specifically the coordination and communication of this care to the primary care physician.
UnitedHealthcare offers you tools such as evidence-based medicine (EBM) guidelines, electronic registries, disease management programs, and other value-added benefits that allow you to focus on the patient. We strive to provide full transparency with regard to how we measure and reward quality. Our focus on partnering with the physician community is evidenced by our ongoing communication with key national societies such as the American College of Physicians (ACP), American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP), as well as our recent creation of a new Primary Care Scientific Advisory Board. This board meets with our leadership on a regular basis to help us better understand the physicians’ needs and to ensure our initiatives can be effective in your practice environment.
To support the Primary Care Management Program quality and efficiency goals, we have a number of initiatives underway including Disease Mangement Programs focusing on asthma and diabetes. Brief overviews of our pilots and some of our disease management programs are provided below:
Patient-Centered Medical Home
UnitedHealthcare, in collaboration with the AAFP, ACP and AAP, has developed an innovative model for value-based, enhanced payment to primary care physicians for delivery of patient-centered care and achievement of quality, economic and satisfaction outcomes. The program will be piloted in one or two states. Based on initial findings, further expansion will be considered.
Asthma Disease Management
We have recently enhanced our Asthma Disease Management Program to target members who have been identified as being high risk asthmatics. High risk asthmatics are identified based on claims information and typically exhibit the following:
One asthma-related IP or ER event
Two or more office visits with an asthma diagnosis and two or more claim dates for inhaled or oral anti-inflammatory or brochodilator medications
Three or more distinct claim dates for inhaled bronchodilator or anti-inflammatory medications and the patient does not have diagnosis (491.xx, 492.xx and 496) in Dx 1 to Dx 5.
The program is overseen by National Jewish Research and Medical Center and supports members through dedicated nursing staff, educational materials and medication compliance reminders. In addition, the program provides an alert to physicians when patients are not complying with medication and provides faxed reports if a patient’s health is deteriorating and action is needed.
The enhancements to the Asthma Disease Management Program are targeting three major value levers within the high risk asthma patient population: inpatient days, readmissions and emergency room utilization.
Targeted interventions include, but are not limited to:
Proactive outreach by respiratory trained nurses
Active discharge planning
Earlier identification and care coordination
Comprehensive environmental assessments
Faxed physician updates on patient deterioration
Diabetes Disease Management
Our Diabetes Disease Management Program is designed to empower individuals to best manage their chronic disease and related conditions, improve adherence to evidence-based medicine treatment plans and medication regimens, reduce unnecessary emergency room visits, hospitalizations and related health care costs, and ultimately improve quality of life.
Participants are identified for program participation via a range of methods including health assessments, program referrals, notifications, predictive modeling and claims data. We then assess the needs of the whole person, their acuity level, potential for impact, readiness to change, and health values and preferences. Our nurses work with the individual to develop a personal care plan and transfer skills and knowledge to help them best manage their condition.
The Diabetes Disease Management Program focuses on the elements that support improved clinical and financial outcomes: the right health care professional, medications, care and lifestyle.
Three key opportunities associated with this program are:
In-patient admission prevention
ER visit reduction
Pharmacy optimization through medication adherence via cost effective alternatives
ER Point of Care Clinical Data Exchange
UnitedHealthcare has begun an ER Point of Care Clinical Data Exchange that provides several hospitals with technology enabling them to quickly obtain and share patient clinical information when UnitedHealthcare members are present in the emergency room.
The goal of this program is to support improved patient care in the ER and post-ER through:
The delivery of relevant clinical information at the point of care to assist the ER with quick and accurate triage and treatment of patients
Timely notification of the patient’s ER visit to their primary care physician to improve care coordination post-ER
Improved coordination with primary care physicians and more timely engagement with UnitedHealthcare’s Care Management resources for patients with chronic conditions
Early data suggest that this type of program could have a significant impact on quality of care, patient safety and care efficiency. It also enables timely follow-up post-ER by UnitedHealthcare’s Nurseline staff and a more immediate connection with the primary care physician to ensure care continuity.