Background
Self-management refers to “the tasks that individuals must undertake to live well with one or more chronic conditions.”1 It includes a wide range of behaviors individuals might focus on to maintain their health—such as monitoring symptoms, adhering to medication regimens, and scheduling visits with clinicians—as well as implementing lifestyle changes by improving diet, exercise, sleep, stress, and pursuing social outlets. Research indicates that self-management improves individuals’ satisfaction with their care, improves health outcomes, and reduces care costs.2 Additionally, self-management increases individuals’ engagement in health care decision making and creates stronger enrollee and care team relationships. For all these reasons, self-management is a key element to integrated, high-quality health care.
Health plans play a pivotal role in establishing supports that enable individuals to achieve self-management success. Self-management support, defined as “assistance provided by clinicians and public health practitioners to enhance an individual’s self-efficacy in managing one or more chronic conditions,”3 increases an individual’s skills and confidence in managing their health problems by establishing processes for goal setting, self-assessment, and problem solving.4 A key factor that distinguishes a clinician’s focus when promoting self-management—as opposed to the traditional top-down power dynamic in which the clinician might simply instruct the individual to change their behaviors—is underlying respect for the individual’s treatment choices. As one nurse practitioner articulates, “It allows you to move from being an adversary…to putting your chairs together to be common problem solvers.”5
Given the high prevalence of chronic conditions among the population dually eligible for Medicare and Medicaid, self-management holds significant promise for improving health outcomes within this demographic.6 However, to be successful at supporting self-management skills and helping individuals monitor progress toward health-related goals, particularly when working with high-risk populations, providers need targeted training, tools, and resources. In practice, supporting enrollees in successfully leveraging self-management strategies requires educating enrollees about addressing their health care needs. It also entails training individuals on available tools and resources (e.g., an enrollee portal) and engaging with community partners.
This post shares learnings from the Resources for Integrated Care (RIC) Integrated Care Community of Practice (ICCoP) on care coordination, an initiative that brought together representatives of plans serving dually eligible individuals for the explicit purpose of discussing promising practices in care coordination approaches. Some ICCoP participants’ self-management support strategies included offering providers and care coordinators training on cultural competence, social determinants of health, motivational interviewing, and various relationship-building frameworks. A common theme among ICCoP participants was the recognition that developing trusting relationships with enrollees enables plans and providers to empower enrollees to take a more proactive approach to their care. In this resource, RIC highlights the journey of one ICCoP participant, Inland Empire Health Plan (IEHP), and identifies promising strategies that IEHP implemented to bolster effective self-management supports among dually eligible individuals. Providers and other plans seeking to strengthen self-management skills among similar enrollees may find IEHP’s experience useful.
Case Study in Self-Management and Care Coordination: Inland Empire Health Plan
IEHP, a not-for-profit Dual Eligible Special Needs Plan (D-SNP) in California, supports more than 1.6 million Medicaid and D-SNP enrollees in Riverside and San Bernardino counties. The information below describes strategies IEHP uses to support self-management and care coordination among dually eligible individuals.
Tailored engagement for new enrollees. IEHP trains all enrollee-facing staff and providers to participate in multidisciplinary care coordination efforts that seek to increase enrollees’ self-management skills. These efforts leverage care coordination strategies that support enrollee engagement, which enhances enrollees’ understanding of their health conditions and agency in establishing care goals. For example, IEHP streamlined its enrollment process for dually eligible individuals—upon enrollment, IEHP immediately connects individuals to the care management team, which initiates the mandatory health risk assessment (HRA). By conducting the HRA without delay and immediately using its results to develop a care plan, IEHP seeks to minimize gaps in care delivery for ongoing services while the individual onboards.
Convening collaborative, interdisciplinary conferences to develop care plans. IEHP collaboratively develops care plans that maximize self-management by convening interdisciplinary conversations with care coordinators, providers, community partners and, when possible, the enrollees themselves. The interdisciplinary care conferences empower enrollees to voice priorities and goals that, in combination with clinical recommendations, serve as care plan development guideposts. Once the conference team finalizes the initial care plan, IEHP connects with the enrollee either weekly or monthly—depending on risk factors—to discuss care progress. If the enrollee raises concerns with any aspect of the care plan, IEHP holds an additional care conference to identify alternative steps that both meet clinical needs and enrollee preferences. Through these efforts, the care plans facilitate continuous enrollee engagement and assessment of any evolving health needs, creating a space for ongoing conversations about the individual’s health goals. In turn, those discussions offer enrollees and providers opportunities to problem solve care management challenges together. This dialogue can further energize the individual to think creatively about strategies for managing their conditions.
Factors driving enrollee contact frequency. When determining the frequency of outreach efforts, the care coordination team stratifies enrollees based on the enrollee’s level of risk for poor health outcomes. The team then conducts at least monthly outreach with enrollees whom IEHP identifies as both high-risk and insufficiently engaged with the health plan; enrollees whom IEHP identifies as low-risk receive less frequent outreach (e.g., every 3-6 months). Matching resources to enrollee need offers providers caring for the most vulnerable individuals with the greatest number of opportunities to connect and employ evidence-based self-management support strategies (e.g., active listening, coaching, teaching problem-solving skills).7
Utilization triggers additional plan outreach. To support care coordination, IEHP’s care transition team contacts every enrollee who is admitted to a hospital to set up a home visit from a nurse or community health worker after discharge. Such home visits enable the team to identify opportunities to provide additional supports that can reduce the likelihood of readmission. Care coordinators might also use this opportunity to link enrollees to community resources (e.g., in-home support services) and follow up on preventative care services (e.g., annual flu shots, mammograms) that help reinforce self-management. In addition to regularly scheduled calls, coordinators also contact enrollees when they observe a change in health status or care utilization (e.g., a hospitalization admission or discharge) to review laboratory results, medication changes, and authorizations. Relatedly, IEHP instituted a utilization management team that prioritizes and processes enrollee requests (e.g., to access services requiring authorization). Leveraging a closed-loop system to track an enrollee’s request, the care coordinator processing the inquiry receives automated prompts to address the request immediately. The system prevents the coordinator from closing the inquiry until after resolving the enrollee-raised concern.
| A Self-Management Support Success Story An Inland Empire Health Plan (IEHP) care coordinator identified an enrollee with multiple chronic conditions who visited the emergency room (ER) and was hospitalized several times because of panic, anxiety, and shortness of breath—all unrelated to their underlying medical conditions. IEHP and the enrollee agreed on a care plan that included weekly home visits from a health navigator and medically tailored low sodium meals prepared by a registered dietician. This approach increased the enrollee’s buy-in and afforded the care coordinator frequent opportunities to confirm that the enrollee was following the plan of care. Additionally, weekly home visits allowed the care coordinator to collect important metrics (e.g., weight, blood pressure, blood sugar) and share frequent updates with the enrollee’s providers. The care team further supported the enrollee in adopting long-term lifestyle changes, including a healthier diet. As a result of these interventions, the enrollee was more engaged with providers and, ultimately, able to self-manage their anxiety. This significantly reduced symptoms and subsequent ER visits. Based on lessons learned from this and other similar experiences—including performance on clinical metrics and enrollee feedback—IEHP increased the frequency of check-ins with enrollees at highest risk for poor outcomes to a weekly cadence to reduce ER visits and hospitalizations. |
Supporting engagement among established enrollees. IEHP leverages a multi-pronged outreach approach to support engagement with established enrollees. When the plan determines that an enrollee is insufficiently engaged, IEHP contacts the individual’s last known provider or pharmacy to confirm up-to-date contact information. IEHP then either directly reaches out to the individual or shares the plan’s contact information with a community-based organization partner to establish a connection between the enrollee and an IEHP care coordinator.
Further leveraging community partners. IEHP also relies upon community partners to help support ongoing enrollee engagement efforts. For example, the plan collaborates with community-based day health programs that integrate behavioral health or social work services or provide enrollees with wellness support opportunities (e.g., exercise classes, cooking lessons). When community partners or providers identify an IEHP enrollee with a specific unmet need (e.g., durable medical equipment, transportation assistance), they inform IEHP by sending referrals that IEHP then addresses.
Additional web-based resources. IEHP supports enrollees’ self-management by sharing important enrollee educational resources on its website. Care coordinators incorporate education efforts into their workflows, coaching enrollees to access online tools that help support their needs. IEHP enrollees can complete a health appraisal, accessible by logging into their enrollee account, both to learn more about their health risks and to access an interactive self-management action plan.
In conclusion, IEHP’s multifaceted and person-centered focus on care coordination and self-management support—including regular assessments, care management, preventative services, behavioral health integration, and enrollee educational resources—helps IEHP’s providers develop trust with enrollees and keep care plans current and reflective of enrollee priorities. These factors strengthen IEHP’s ability to simultaneously reinforce self-management supports and care coordination strategies that, together, can lead to improved health outcomes.
Resources
- Promising Practices For Utilizing Motivational Interviewing (MI) To Improve Care Coordination And Address Social Determinants Of Health (SDOH) – RIC
- Health Coaching And Wellness Planning To Increase Client Engagement In Self-Management: A Conversation With Judith Cook – RIC
- What To Expect When You’re Self-Managing: A Client Handout For Behavioral Health Providers – RIC8
- Action Plan Selection Guide – A Tool For Self-Management Support – RIC
- Self-Management Support In Behavioral Health: Organizational Assessment Tool – RIC
- Approaches To Supporting Self-Management For Individuals With Serious Mental Illness – RIC
- Taking Charge! Evidence-Based Self-Management Programs – RIC
- What is the State of Patient Self-Management Support Programs? An Evaluation – Agency for Healthcare Research and Quality (ahrq.gov)
- Why Is Self-Management Support Important? (ahrq.gov)
Endnotes
1Agency for Healthcare Research and Quality. (2017). What is the State of Patient Self-Management Support Programs? An Evaluation. Retrieved from https://www.ahrq.gov/research/findings/final-reports/selfmgmt/selfmgmt3.html.
2Dineen-Griffin, S., Garcia-Cardenas, V., Williams, K., & Benrimoj, S. I. (2019). Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice. PloS One, 14(8). Retrieved from https://doi.org/10.1371/journal.pone.0220116.
3Centers for Disease Control and Prevention. (2023). Self-Management Support and Education. Retrieved from https://hdsbpc.cdc.gov/s/article/Self-Management-and-Education.
4Adams, K., & Corrigan, J. M. (2003). Priority Areas for National Action: Transforming Health Care Quality. Washington, D.C.: National Academies Press.
5AHRQ Primary Care. (2014, January 10). Why Is Self-Management Support Important? [Video]. YouTube. Retrieved from https://www.ahrq.gov/ncepcr/tools/self-mgmt/why.html. Transcript available at https://www.ahrq.gov/ncepcr/tools/self-mgmt/why-script.html.
6Palmieri, C., Kagan, J., Smith, L., Kiel, M., & Soper, M. (2022). Integration Of Medicare And Medicaid Services Is Essential For Dually Eligible Individuals With Behavioral Health Needs. Health Affairs Forefront. Retrieved from https://www.healthaffairs.org/content/forefront/integration-medicare-and-medicaid-services-essential-dually-eligible-individuals.
7AHRQ National Center for Excellence in Primary Care Research. (2016). How to Incorporate Self-Management Support into Your Practice [Video Transcript]. Retrieved from https://www.ahrq.gov/ncepcr/tools/self-mgmt/how-script.html.
8This resource is available in both English and Spanish.