Clinical Update - Winter 2006

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www.amerihealth.com
INSIDE THIS ISSUE
WINTER 2006
• 2006 ConnectionsSM Programs Annual Update Enclosed ............................................................... 2
• Crohn’s Disease Added to the ConnectionsSM AccordantCare™ Program ........................................ 2
• Supporting Our Members, Your Patients: ConnectionsSM Health Management Programs ................... 3
• SMART™ Registry Release for January 2007 ............................................................................... 4
• Using the Estimated Glomerular Filtration Rate to Track and Diagnose
Impaired Kidney Function Early ................................................................................................... 5
• Celiac Disease: Increasing Awareness and Addressing the Diagnostic Challenge ............................ 6
A
VIEW
INSIDE
FROM
THE
MEDICAL
DIRECTORS
We are pleased to bring you the Winter Clinical Update. In this issue, we announce the addition of Crohn’s disease to
the ConnectionsSM AccordantCareTM Program (on page 2) designed to improve the quality care of our members. To
provide you with accurate and valuable health care information, we have also included:
• Recent findings to assist you in the diagnosis and treatment of celiac disease.
• The SMARTTM Registry Release for January 2007.
• The stages of chronic kidney disease and the Estimated Glomerular Filtration Rate test.
We hope you consider Clinical Update a valuable resource for current clinical information. It is our goal, through
Clinical Update and our other publications, to help keep you and your staff aware of the latest administrative, clinical,
and policy information.
Allan B. Goldstein, M.D., F.A.C.P
Vice President and Regional Medical Director
New Jersey
(732) 726-6796
Ronald J. Brooks, M.D.
Senior Medical Director
Delaware
(215) 640-7675
2006 ConnectionsSM Programs Annual
Update Enclosed
We offer disease management and decision
support for 22 chronic conditions. In addition to
extensive disease-specific member information,
the ConnectionsSM Programs also offer providerfocused support.
Please be sure to see the enclosed 2006
ConnectionsSM Programs Annual Update to read
about:
• New clinical updates, including clinical
evidence and Clinical Insights.
• Highlights of the Connections Programs’
progress over the past year.
• Ways in which the programs have supported
quality care to our members.
• New tools and resources available to you and
your patients.
• Telephone numbers to contact the
Connections Programs.
Crohn’s Disease Added to the ConnectionsSM
AccordantCareTM Program
In a continuing effort to support our members with
chronic conditions, Crohn’s disease will be added
to the list of complex chronic diseases managed
through the ConnectionsSM AccordantCare™
Program, effective December 1, 2006. The
Connections AccordantCare Program is offered
in partnership with Accordant Health Services
(Accordant), a Caremark® company.
Similar to other conditions that are part of the
Connections AccordantCare Program, Crohn’s
disease is complex, affects a significant segment
of the membership, and has complications that
may be avoidable. With the addition of Crohn’s
disease, the Connections AccordantCare Program
will continue to focus on educating members
about their disease, including the importance of
reporting symptoms to their doctor and adherence
to providers’ treatment plans.
The Connections AccordantCare Program is
available to members with any of the following
16 diseases:
•
•
•
•
•
•
•
•
•
•
•
Multiple Sclerosis
Crohn’s Disease
Parkinson’s Disease
Systemic Lupus Erythematosus (SLE)
Myasthenia Gravis
Sickle Cell Disease
Cystic Fibrosis
Hemophilia
Scleroderma
Polymyositis
Chronic Inflammatory Demyelinating
Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease
For more information about the program, visit
www.accordant.com or call (866) 398-8761.
• Seizure Disorders
• Rheumatoid Arthritis
2
Winter 2006
www.amerihealth.com
Supporting Our Members, Your Patients:
ConnectionsSM Health Management Programs
CONNECTIONSSM HEALTH MANAGEMENT PROGRAM
Diseases: Asthma, CHF, CAD, COPD, Diabetes
Additional 2006 Decision Support Initiatives:
• Weight Loss Surgery – For more information, please refer to May 2006 Partners in
Health Update
• Depression Screening – For more information, please refer to Spring 2006 Clinical Update
To refer a patient or obtain additional information – call the ConnectionsSM Health Management
Program Provider Support Line at (866) 866-4694.
CONNECTIONSSM ACCORDANTCARE TM PROGRAM
Diseases:
• Seizure Disorders
• Rheumatoid Arthritis
• Multiple Sclerosis
• Crohn’s Disease
• Parkinson’s Disease
• Systemic Lupus Erythematosus (SLE)
• Myasthenia Gravis
• Sickle Cell Disease
• Cystic Fibrosis
• Hemophilia
• Scleroderma
• Polymyositis
• Dermatomyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Gaucher Disease
To refer a patient or obtain additional information – call the ConnectionsSM AccordantCareTM
Program at (866) 398-8761.
CONNECTIONSSM KIDNEY PROGRAM
Diseases: End-Stage Renal Disease (ESRD)
To refer a patient or obtain additional information – call the ConnectionsSM Kidney Program
at (866) 303-4CKP [4257].
www.amerihealth.com
Winter 2006
3
SMARTTM Registry Release for January 2007
The next release of the SMART™ Registry
is scheduled for January 2007. This release
will continue with diabetes as the targeted
clinical initiative, specifically looking at diabetic
retinopathy screening gaps and co-morbidity of
hypertension through angiotensin-converting
enzyme (ACE) inhibitors and angiotensin
receptor blockers (ARB) medication gaps. The
SMART Registry will include a Disease-Specific
Group Report on all your patients with diabetes,
as well as a special article on the importance of
microalbuminuria detection and monitoring.
4
Winter 2006
Provider Service Specialists (PSSs) can meet
with doctors and other clinical office staff to
review your practice’s SMART Registry and to
help with referrals to the ConnectionsSM Health
Management Program. PSSs can provide diabetes
education tools, including the Diabetes Wallet
Card and Body Mass Index Card. Doctors can also
request reports filtered for other conditions, or a
CD version of the SMART Registry.
To speak with a PSS about the SMART Registry
or any other aspect of the Connections Program,
call the Provider Support Line at (866) 866-4694.
www.amerihealth.com
Using the Estimated Glomerular Filtration
Rate to Track and Diagnose Impaired Kidney
Function Early
The American Heart Association (AHA)
recommends kidney disease screening for all adults
with cardiovascular disease or cardiovascular risk
factors. According to the AHA, chronic kidney
disease (CKD) is common in patients with
cardiovascular disease and is also a major risk
factor for progressive cardiovascular disease. CKD,
however, frequently remains undetected.
According to the National Kidney Foundation,
calculating the Estimated Glomerular Filtration
Rate (e-GFR) is the best test to determine kidney
Stage of
Chronic Kidney
Disease
function. The e-GFR can be derived simply from
a formula using the results of a serum creatinine
test by factoring in the patient’s age, race, and
gender. Many labs automatically return the e-GFR
when a serum creatinine is ordered alone or part
of a chemistry panel. Some states have passed laws
mandating e-GFR reporting for adult specimens.
Other labs return the e-GFR only as an option,
which the doctor has to select. The following chart
shows the relationship of GFR and the progression
of CKD stages.
Glomerular
Filtration Rate
(GFR) in cc/min.
Description
Risk factors for kidney disease (e.g.,
At increased risk diabetes, high blood pressure, family
history, older age, ethnic group)
•
90 and above
•
•
1
Kidney damage (protein in the urine)
and normal GFR
90 and above
2
Kidney damage and mild decrease in
GFR
60 to 89
•
•
•
3
Moderate decrease in GFR
30 to 59
•
4
Severe decrease in GFR
5
Kidney failure (dialysis or kidney
transplant needed)
To obtain the codes to order the e-GFR, please
reference the March 2006 edition of Partners in
Health Update or contact your lab representative.
For additional information about GFR and other
kidney-related topics, visit the National Kidney
Foundation at www.kidney.org. There are also
www.amerihealth.com
15 to 29
Less than 15
•
Opportunities for
Intervention
Screening and
identification
Treatment of co-morbid
disease
Screening and
identification
Treatment of co-morbid
disease
Treatment of co-morbid
disease (e.g., aggressive
blood pressure control)
Testing and treating for
common complications
of CKD (i.e., anemia,
hyperparathyroidism)
Planning for Renal
Replacement Therapy
(RRT) (dialysis and/or
transplantation)
Permanent vascular
access and initiation
of RRT
several websites, such as www.nkdep.nih.gov, that
can perform the e-GFR calculation.
Note: As of September 11, 2006, Quest Diagnostics
labs will return the e-GFR with the serum creatinine.
Winter 2006
5
Celiac Disease: Increasing Awareness and
Addressing the Diagnostic Challenge
Prevalence of Celiac Disease
Recent developments have brought attention
to celiac disease and the diagnostic challenge
presented by this condition. Previously thought to
be a rare childhood disease, celiac disease has been
reclassified by the National Institutes of Health
(NIH) as a common disease that can affect any
age group, even into the eighth decade of life.
The NIH also stated that celiac disease is widely
overlooked. At the first-ever NIH Consensus
Development Conference on Celiac Disease in
June 2004, the panel determined that its prevalence
is much greater than previous estimates and it
possibly affects as many as three million Americans
(roughly one percent of the U.S. population).1
Diagnosis of Celiac Disease
Primary care physicians play a critical role in
identifying and managing celiac disease. The
key to making a prompt and correct diagnosis
is recognizing possible symptoms that may give
rise to celiac disease. Recent identification of the
autoantigens involved in celiac disease has led to
the development of new serologic diagnostic tests
that are identifying many celiac patients with
nonclassic gastrointestinal (GI) and extraintestinal
symptoms.2
All diagnostic tests need to be performed while
the patient is on a gluten-containing diet. The
NIH recommends a serologic test (celiac panel or a
comprehensive celiac sprue panel) as the first phase
in diagnosis. The specific antibody tests should
include:
• IgA endomysial antibody immunofluorescence
(IgA EMA).
• IgA antihuman tissue transglutaminase
(IgA tTG).
• Anti-gliadin antibody (AGA).
Etiology and Symptoms of Celiac
Disease
Celiac disease is a T-cell-mediated inflammatory
response to gluten that can cause both GI and
non-GI symptoms.3 Gluten is a protein that is
found in wheat, rye, and barley. The disease is
6
Winter 2006
characterized by chronic inflammation of the
small intestinal mucosa that may result in atrophy
of intestinal villi, malabsorption, and a variety of
clinical manifestations that may begin in either
childhood or adult life.
Symptoms of celiac disease are varied and can
include any of the following:
• Recurring abdominal bloating, gas, pain,
chronic diarrhea, or constipation
• Fatigue
• Weight loss
• Unexplained anemia
• Bone or joint pain
• Behavioral changes
• Muscle cramps
• Delayed growth in children or failure to thrive
in infants
• Neurologic symptoms, including paresthesias
and seizures
• Oral aphthous ulcers
• Dermatitis herpetiformis
• Tooth discoloration or loss of enamel
• Menstrual irregularity, infertility, or recurrent
miscarriage
Celiac disease is often misdiagnosed as irritable
bowel syndrome or other functional bowel
disease. The NIH has concluded that the classic
presentation of diarrhea and malabsorption is less
common, and atypical, and that silent presentations
are increasing.
The NIH defines four categories of
celiac disease
1. Classical celiac disease is dominated by
symptoms and sequelae of gastrointestinal
malabsorption. The diagnosis is established by
serological testing, biopsy evidence of villous
atrophy, and improvement of symptoms on a
gluten-free diet.
2. Celiac disease with atypical symptoms is
characterized by few or no GI symptoms, and
extraintestinal manifestations predominate.
www.amerihealth.com
Celiac Disease: Increasing Awareness and Addressing
the Diagnostic Challenge (continued)
Recognition of atypical features of celiac
disease is responsible for much of the increased
prevalence, and now may be the most common
presentation. As with classical celiac disease,
the diagnosis is established by serologic
testing, biopsy evidence of villous atrophy, and
improvement of symptoms on a gluten-free
diet.
3. Silent celiac disease refers to individuals who
are asymptomatic, but have a positive serologic
test and villous atrophy on biopsy. These
individuals usually are detected via screening
of high-risk individuals, or villous atrophy
occasionally may be detected by endoscopy and
biopsy conducted for another reason.
4. Latent celiac disease is defined by a positive
serology, but no villous atrophy on biopsy.
These individuals are asymptomatic, but later
may develop symptoms and/or histologic
changes.
immune response and induce tissue damage. Most
affected individuals experience remission after
excluding gluten from their diet.
Treatment of Celiac Disease
The only known treatment for celiac disease is
lifelong adherence to a gluten-free diet. This is
a diet that is free of all wheat (including spelt,
triticale, and kamut), rye, and barley as these grains
contain the peptides or glutens known to cause
celiac disease. Even small quantities of gluten
may be harmful. Oats appear to be safe for use by
most individuals with celiac disease. Despite these
restrictions, people with celiac disease may eat a
well balanced diet with a variety of foods, including
gluten-free bread and pasta, and non-gluten
alternatives, such as potato, rice, soy, or bean flour.
Resources
• The Delphi Forum is one of several online
resources that list gluten-free foods from
many manufacturers. The forum website is
http://forums.delphiforums.com/celiac. Scroll
down to Forum Folders and then click on
Gluten-Free Products Lists.
• The American Dietetic Association
(ADA) also has developed a guide for
a gluten-free diet. The ADA website is
www.eatright.org/Public.
• In addition, the National Foundation for
Celiac Awareness (NFCA) has a dietary guide
and other useful information on its website,
www.celiacawareness.org.
Celiac disease is associated with a
number of other conditions:
• Autoimmune diseases, including Type 1
diabetes, autoimmune myocarditis, neuropathy,
and primary biliary cirrhosis
• GI cancers, such as oropharyngeal, esophageal,
intestinal, hepatobiliary and pancreatic cancers,
and lymphoproliferative malignancies, such as
T-cell and non-Hodgkin’s lymphomas
• Dermatological conditions, such as dermatitis
herpetiformis
• Thyroid problems, reproductive health issues,
anemia, vitamin and mineral deficiencies, and
osteoporosis
Considerable scientific progress has been made in
understanding celiac disease and in preventing or
curing its manifestations by dietary interventions.
There is a strong genetic predisposition to celiac
disease, with the major risk attributed to the
specific genetic markers known as HLA-DQ2 and
HLA-DQ8 that are present in affected individuals.
Dietary proteins present in wheat, barley, and rye,
commonly known as glutens, interact with these
HLA molecules to activate an abnormal mucosal
www.amerihealth.com
Notes:
The National Foundation for Celiac Awareness (NFCA) provided this
article. The NFCA mission is to advance research, education, and screening,
and improve the quality of life for children and adults affected by celiac
disease. To learn more about the NFCA, go to www.celiacawareness.org.
“Final Statement, National Institutes of Health Consensus Development
Conference Statement on Celiac Disease, August 9, 2004” from:
http://consensus.nih.gov/cons/118/118celiac.htm.
1
2
Ibid.
“Demystifying celiac disease,” Chico, MD, Gavin F., Chico, MD,
Michelle A. Patient Care, published March 1, 2005. From:
www.patientcareonline.com/patcare/article/articleDetail.jsp?id=150945
3
Winter 2006
7
ADVISORY BOARD
Allan B. Goldstein, M.D.,
F.A.C.P.
Vice President and
Regional Medical Director,
New Jersey
Henry P. Schwerner, M.D.
Medical Director,
Northern New Jersey
Stephen G. Friedhoff, M.D.
Medical Director,
Southern New Jersey
Ronald J. Brooks, M.D.
Senior Medical Director,
Delaware
AmeriHealth
1901 Market Street
35th Floor
Philadelphia, PA 19103
AmeriHealth products are offered
by AmeriHealth HMO, QCC Insurance
Company d/b/a AmeriHealth Insurance
Company, and AmeriHealth Insurance
Company of New Jersey.
The third-party websites mentioned in this
publication are maintained by organizations
over which AmeriHealth exercises no
control, and accordingly, AmeriHealth
disclaims any responsibility for the content,
the accuracy of the information, and/or
quality of products or services provided
by or advertised in these third-party sites.
URLs are presented for informational
purposes only.
Certain services/treatments referred to in
other sites may not be covered by all benefit
plans. Members should refer to their benefit
contract for complete details of the terms,
limitations, and exclusions of their coverage.
This is not a statement of benefits. Benefits
may vary based on state requirements,
product line (HMO, PPO, Indemnity, etc.),
and/or employer groups. Providers should
call Provider Services, listed above, for the
member’s applicable benefit information.
Members should be instructed to call the
number on the back of their identification
card.
Not all benefit plans use Magellan
Behavioral Health, Inc. to administer
behavioral health benefits. Please check
the back of the member’s ID card for the
telephone number to contact for behavioral
health services, if applicable.
Visit our website
www.amerihealth.com
Frequently Dialed Numbers
American Imaging Management (AIM)
(800) 859-5288
(Call for CT, MRI/MRA, PET, and Nuclear
Cardiology for AmeriHealth NJ members only)
Care Management and Coordination
Hours: Mon-Fri 8:00 AM–5:00 PM
Baby FootSteps® (Perinatal Case Management)
Nurse on call 24-hours-a-day
Clinical Pharmacy Services
Prescription Drug Preauthorization
(888) 678-7012
To precertify specific prescription drugs (i.e., Provigil®, Thalomid®,
Enbrel®) or drug classes (Cox-2 inhibitors, erectile dysfunction drugs).
You may also call to receive full list of prescription drugs requiring
precertification.
Hours: Mon-Fri 9:00 AM–5:00 PM
Pharmacy Appeals
Blood Glucose Meter Hotline
Connections
SM
(800) 313-8628
(800) 598-BABY (2229)
Toll-free Fax: (888) 671-5285
(888) 494-8213 (Option 1)
(888) 494-8213 (Option 2)
Health Management Programs (Disease Management and Decision Support)
ConnectionsSM Health Management Program
Provider Support Line
Member Access Number
ConnectionsSM AccordantCareTM Program
ConnectionsSM Kidney Program
(866)
(800)
(866)
(866)
866-4694
275-2583
398-8761
303-4CKP (4257)
Corporate and Financial Investigations Department
Anti-Fraud and Corporate Compliance Hotline
Credentialing Violation Hotline
(866) 282-2707
(215) 988-6534
Customer Service/Member Services
AmeriHealth HMO
Hours: Mon-Fri 8.00 AM–6:00 PM
AmeriHealth PPO
Hours: Mon-Fri 8:00 AM–6:00 PM
AmeriHealth 65®
Hours: Mon-Fri 8:00 AM–6:00 PM
(800) 877-9829 (NJ)
(800) 444-6282 (DE)
(800) 422-2457
(800) 645-3965
Health Resource Center
AmeriHealth Healthy LifestylesSM
Hours: Mon-Fri 8:00 AM–6:00 PM
Precertification
(800) 275-2583
(800) 227-3116
Mental Health/Substance Abuse
Magellan Behavioral Health, Inc.
Member Services/Precertification
Hours: 24-hours-a-day/7-days-a-week
NaviMedix®
Technical assistance for current users
NaviNetSM
Portal Registration and Questions
(800) 809-9954
(888) 482-8057
(856) 638-2701 (NJ)
(302) 661-6111 (DE)
Provider Services
HMO Policies/Procedures/
Eligibility/Claims
Hours: Mon-Fri 8:00 AM–6:00 PM
PPO Policies/Procedures/Claims
Hours: Mon-Fri 8:00 AM–6:00 PM
The Provider Supply Line
(800)
(800)
(800)
(800)
821-9412 (NJ)
888-8211 (DE)
227-3119 (PA)
595-3627
(800) 858-4728
ALL
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TRADES
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LABEL
COUNCIL
SCRANTON
13
ConnectionsSM Health Management Programs
2006 ANNUAL UPDATE
ConnectionsSM Programs Annual Update: A Summary
ConnectionsSM Health Management Program.......................................................2
ConnectionsSM Kidney Program...........................................................................2
ConnectionsSM AccordantCare™ Program ...........................................................2
2006 Update on Our Connections Programs
ConnectionsSM Health Management Program.......................................................4
Diabetes Targeted Provider Outreach ..............................................................4
New Tools and Resources for Providers and Patients ........................................5
The SMARTSM Registry ...................................................................................6
New Decision Support Campaigns .................................................................6
Provider Satisfaction Survey ...........................................................................7
Member Satisfaction Survey ...........................................................................7
ConnectionsSM Kidney Program...........................................................................7
ConnectionsSM Kidney Program Quality Care Committee ..................................8
ConnectionsSM Kidney Program Clinical Indicators ...........................................8
ConnectionsSM AccordantCare™ Program .........................................................10
Program Diseases .......................................................................................10
Clinical Practice Guidelines and Clinical Insights ................................................11
AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • QCC Insurance Company d/b/a AmeriHealth Insurance Company
ALL
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TRADES
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LABEL
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13
Annual Update 2006
ConnectionsSM Health Management Programs
CO N N E C T I O N S SM PR O G R A M S A N N U A L U P D AT E S U MMARY
Our ConnectionsSM Annual Update highlights
the accomplishments made by our Connections
Programs during the past year. The goal of
Connections is to help people with chronic
illnesses lead healthier lives. Connections covers
a total of 22 chronic conditions, offering decision
support and health information, and includes
three different specialized programs:
• ConnectionsSM Health Management Program:
Focusing on five common chronic diseases, such
as diabetes and asthma
• ConnectionsSM Kidney Program: Managing
end-stage renal disease
• ConnectionsSM AccordantCareTM Program:
Living with 16 complex chronic diseases
ConnectionsSM Health
Management Program
We continue to offer the Connections Health
Management Program in partnership with Health
Dialog to provide disease management and decision
support services to members 24-hours-a-day,
7-days-a-week, through Health Coaches and online
resources. The disease-management portion of
the program focuses on five of the most common
chronic conditions — asthma, chronic obstructive
pulmonary disease (COPD), chronic heart failure
(CHF), coronary artery disease (CAD), and diabetes.
The decision support component helps members
facing treatment decisions for conditions such as:
acute and chronic back pain, breast cancer, prostate
disease, and weight loss surgery, and supports
members with end-of-life issues. Health Coaches are
also available to answer general medical questions at
any time of the day or night. Members can receive
free DVDs, videos, and informational materials,
through the mail, from their Health Coach.
ConnectionsSM Kidney
Program
For members with end-stage renal disease (ESRD)
on chronic outpatient dialysis, we provide the
Connections Kidney Program in collaboration with
RMS Disease Management Services. The program
2
utilizes Health Service Coordinators (HSCs), who
are experienced renal nurses, to meet with members
at dialysis centers or at the member’s home. They
provide information and support to members and
their families regarding ESRD and co-morbid
conditions. HSCs also work with doctors to
implement provider care plans for their patients.
ConnectionsSM
AccordantCareTM Program
Working with Accordant Health Services, we
provide disease management for members with one
or more of 16 complex, chronic conditions through
the Connections AccordantCare Program. The
diseases include:
•
•
•
•
•
•
•
•
•
•
•
•
•
Seizure Disorders
Rheumatoid Arthritis
Multiple Sclerosis
Crohn’s Disease (effective 12/1/06)
Parkinson’s Disease
Systemic Lupus Erythematosus (SLE)
Myasthenia Gravis
Sickle Cell Disease
Cystic Fibrosis
Hemophilia
Scleroderma
Polymyositis
Chronic Inflammatory Demyelinating
Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease
Members have access to nurses who can work with
them to develop care plans, support the member’s
effort to adhere to their doctor’s treatment plan,
provide information about community resources and
help groups, and much more. The AccordantCare
nurses also communicate with the member’s doctors
to update them on urgent situations or when there
has been a change in the member’s health status.
Through the program, members receive diseasespecific and general health newsletters, educational
mailings, flu vaccination reminders, access to the
Accordant website, and more.
Provider Contact
Information
Member Contact
Information
ConnectionsSM Health
Management Program
(866) 866-4694
(800) 275-2583, prompt 2
www.amerihealthexpress.com
ConnectionsSM Kidney Program
(866) 303-4CKP [4257]
(866) 303-4CKP [4257]
ConnectionsSM AccordantCareTM
Program
(866) 398-8761
www.accordant.net
Select “Physicians,” and
then click on “Care
Management Profile”
provider log-in/password =
AmeriHealthMD/197726
(866) 398-8761
www.accordant.com
Annual Update 2006
Connections Program
ConnectionsSM Health Management Programs
ConnectionsSM Programs Reference Table
3
Annual Update 2006
ConnectionsSM Health Management Programs
2 0 0 6 U P D AT E O N O U R C O N N E C T I O N S SM P R O G RAMS
ConnectionsSM Health
Management Program
The Connections Health Management Program
(CHMP) offers disease management services to
members with one or more of the most prevalent
chronic conditions — asthma, chronic obstructive
pulmonary disorder (COPD), chronic heart failure
(CHF), coronary artery disease (CAD), and diabetes.
The program also provides decision support to
members facing medical decisions such as selecting a
treatment option or considering whether to undergo
surgery.
Diabetes Targeted Provider Outreach
In February 2006, the CHMP started a clinical
initiative to assist providers caring for patients with
diabetes. CHMP Provider Service Specialists (PSSs)
met with physicians and other clinical practitioners
to discuss the January SMART™ Registry data.
They provided referral tools and resource cards for
use by both physicians and patients. Referrals link
patients with Health Coaches, who work with them
by telephone to help patients better manage their
chronic disease. Health Coaches can assist patients
by helping them enhance self-management skills,
such as adhering to medication and treatment plans
and developing and using a Symptom Response
Plan. Since the start of this campaign:
• PSSs have visited more than 425 practices and
spoken directly with 175 clinicians.
• Visited providers have referred more than 470
additional members with diabetes for Health
Coaching.
• Clinicians have provided feedback for more than
250 members with diabetes.
PSSs have found that filtering the SMART Registry
to focus on subgroups of patients with a chronic
illness makes the Registry more manageable and
easier for physicians to design strategies that
effectively address care gaps. For example, practices
may place the Patient-Specific Reports in patient
charts as a reminder to close specific gaps at the
time of the patient’s office visit. Other practices use
the Registry to identify and refer patients who may
benefit from an ongoing relationship with a Health
Coach.
An enhancement to the June 2006 SMART Registry
helps physicians decide which patients to refer to
Health Coaching. A column has been added to
indicate whether a patient is engaged in Health
Coaching. Now the provider can immediately
identify patients who are not already engaged in
Health Coaching and can make referrals when
appropriate. As part of the diabetes initiative, PSSs
also introduced a new provider tool that addresses
microalbuminuria testing as a means of detecting
early nephropathy. This brochure outlines the
importance of:
• The timing of microalbuminuria screening/
monitoring in different types of patients with
diabetes.
• Medication and other management of patients
with microalbuminuria.
• Other general diabetic management issues, such
as a written action plan, weight control, and eye
and foot care.
For more information about the diabetes initiative,
the ConnectionsSM Health Management Program
provider tools, or to speak with a PSS, please call the
CHMP Provider Support Line at (866) 866-4694.
More information on the SMART Registry can be
found on page 6.
4
New Provider and Patient Tools
• PHQ-9 Depression Screening tool: This
nine question Patient Health Questionnaire
is a screening tool available to members and
providers. It comes with scoring directions
for both providers and members, and, for
members, the recommendation that they
complete the tool and take it to their provider.
• Obesity Resource Card: This existing tool is
now available to providers with an additional
Body Mass Index (BMI) insert card, which
discusses the program’s Weight Loss Surgery
decision support campaign.
• Shared Decision-Making® Brochure: This
brochure has both a member and provider
version. It gives an overview of what the
shared decision-making process is, explains
how Health Coaches can assist the members
in this process, and lists all Shared DecisionMaking® program videos.
• Microalbuminuria Brochure: This brochure
emphasizes the importance of annual
microalbumin testing and includes a list of
items to review at each office visit for patients
with diabetes.
• Referral pad and fax referral form: Both
tools have been updated to include check
boxes for depression screening and weight loss
surgery.
Shared Decision-Making programs are available
on VHS and DVD. The following programs were
released in 2006:
• Weight Loss Surgery: Is It Right for You? is
available to members who are considering
weight loss surgery.
• Coping With Symptoms of Depression is now
available for people who are wondering
whether they have depression or who have
been diagnosed with depression and must now
select a treatment option.
• Managing Menopause: Choosing Treatments for
Menopause Symptoms is a video for women
ages 40 to 60 who have questions about
managing common menopause symptoms.
• Hormone Therapy: When the Prostate-Specific
Antigen (PSA) Rises after Prostate Cancer
Treatment is for men who have a rising PSA
level after their prostate cancer has been
treated with surgery or radiation and who
are facing a treatment decision on whether to
have hormone therapy.
• Getting the Healthcare That’s Right for You
is for members who would like to be more
actively involved in their health care and work
with their doctors to make informed medical
decisions.
Annual Update 2006
If you would like to receive any of the following
materials, please contact the Provider Support Line
at (866) 866-4694.
New Shared Decision-Making® Programs
Released in 2006
ConnectionsSM Health Management Programs
New Tools and Resources
for Providers and
Patients
Providers can also find information and
resources at www.amerihealth.com/providers. This
website includes the physician fax referral form,
Connections Program contact information, a
SMARTTM Registry sample, and more.
5
Annual Update 2006
ConnectionsSM Health Management Programs
The SMARTSM Registry
In 2006, we distributed two releases of the SMART
Registry. The SMART Registry tracks important
evidence-based aspects of care for patients with one
or more of the following chronic conditions: asthma,
CAD, COPD, CHF, and diabetes. The SMART
Registry is designed to provide clinical information
at the point of care and help physicians:
• Identify patients in their practice who have
chronic diseases and co-morbidities.
• Identify patients for whom there may
be significant opportunities for clinical
improvement.
• Identify practice-wide opportunities to
enhance evidence-based practice and decrease
inappropriate variation in effective care.
• Improve clinical quality and outcomes for their
patients.
January 2006 Overview:
The January 2006 SMART Registry included
a diabetes disease-specific report as part of the
Diabetes Targeted Clinical Initiative. This report
provides a practice-wide overview of a practice’s
patients with diabetes, including a status on
recommended tests and procedures. The January
Registry was mailed to 1,173 practices and
included more than 7,512 members with at least
one of the five chronic conditions.
June 2006 Release Overview:
The June 2006 SMART Registry also included the
diabetes disease-specific report. This release was
enhanced by the addition of a column to identify
members who have been in contact with a Health
Coach. The June Registry was mailed to 1,208
practices and included more than 8,015 members
with chronic conditions.
The SMARTTM Registry is an easy-to-use resource
designed to help your practice identify your patients
with chronic conditions and help you deliver
recommended tests and treatments. This tool is
available in both a hard copy version and on a CD
which offers significant sorting capabilities to users.
PSSs can show your practice how to use the Registry
and identify opportunities to improve the quality of
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care for your patients with chronic conditions. PSSs
can schedule delivery of the SMART Registry CD at
a time that is most convenient for your office.
New Decision Support Campaigns
In 2006, the ConnectionsSM program launched
two new decision-support campaigns to assist our
members.
Depression Screening Decision Support Campaign
In March 2006, the Connections program
implemented the Depression Screening decision
support campaign. The goal of the campaign is to
identify undiagnosed and/or untreated depression
in members. The program targets members at
increased risk for depression based on existing comorbid chronic conditions such as diabetes, heart
conditions, migraines, and back pain. Identified
members are mailed a letter introducing the
program along with the PHQ-9, a self-administered
depression screening tool. Members are instructed
to take the completed tool with them to their next
doctor visit. Select patients will also receive an
automated phone call with the option of transferring
to a Health Coach.
In conjunction with the member mailing, a
Depression Screening educational toolkit is available
for providers. PSSs delivered the toolkit to primary
care physicians (PCPs) whose patients received the
Depression Screening mailing. The provider kit
includes the PHQ-9 Depression Screening tool,
the Depression Scoring card, and program referral
materials.
Weight Loss Surgery Decision Support Campaign
In June 2006, the Connections program offered the
new weight loss surgery decision-support campaign
to patients who may be considering bariatric
surgery. The program is designed to help members
understand the benefits and risks of weigh loss
surgery, to provide an overview of surgery options,
and to educate members on what to expect after
surgery. Health Coaches are available to discuss
alternatives to surgery, preparation required for
surgery, post-surgery nutrition issues, and potential
complications. If appropriate, members can receive a
new evidence-based video, Weight Loss Surgery: Is It
Right for You?
Provider Satisfaction Survey
The Annual Provider Satisfaction Survey was
conducted in late 2005. Facilitated by Atlantic
Research and Consulting, AmeriHealth providers
received a Connections Health Management
Program Provider Survey along with an incentive
for completing the survey. The results of the survey
showed that:
• More than one-fourth of AmeriHealth providers
indicated that patients had discussed the
Connections Program with them.
• Nearly two-thirds found the SMART
helpful.
TM
Registry
• 38% found the Provider Service Specialist (PSS)
support helpful.
• Two-thirds indicated that the Connections
Program provided a more positive image of
AmeriHealth.
• Overall, 77% of AmeriHealth providers
responded that their patients with chronic
conditions who used the Connections Program
found it helpful.
Member Satisfaction Survey
Each year, we survey a sample of members to
determine their level of awareness, use, and
satisfaction levels with the ConnectionsSM Health
Management Program. The survey is conducted
telephonically by Atlantic Research and Consulting
late in the year. The 2005 survey sample population
included members with and without one of the five
managed chronic conditions, members who have
had telephone contact with a Health Coach, and
members who have never spoken to a Health Coach.
• 89% of members with a chronic condition and
89% of members without a chronic condition
indicated they were satisfied with the Health
Coaching assistance they received.
• 89% of members with a chronic condition and
86% of members without a chronic condition
said their impression of AmeriHealth was
positively impacted because of the Connections
Program.
• 78% of members with a chronic condition and
76% of members without a chronic condition
surveyed said it was important for AmeriHealth
to continue to offer the Connections Program.
• Members reported they called a Health Coach to
gather information about an illness or condition
that they or a family member have, and to get
help understanding treatment options, choosing
among the options, and managing a chronic
illness.
ConnectionsSM Kidney
Program
Since its launch more than two years ago,
nearly 2,000 members have been referred to the
Connections Kidney Program (CKP). Currently,
there are approximately 500 active members in the
program. Members who enroll in the Connections
Kidney Program are assigned a personal Health
Service Coordinator (HSC), an experienced
dialysis nurse who visits members at their dialysis
centers and at their homes and who conducts
telephone support and follow-up. Working with the
members and their physicians, the HSC encourages
compliance and understanding of their total care
plan. In addition, the HSC supports members with
other chronic conditions that may be present in
addition to end-stage renal disease (ESRD).
Annual Update 2006
PSSs can visit practices to provide more information
about these new campaigns or about the
ConnectionsSM Program in general.
The survey shows that:
ConnectionsSM Health Management Programs
An educational toolkit is also available for providers.
The toolkit includes a program introductory
letter and educational material to PCPs, such as
a BMI resource card and a patient handout with
information about diet and exercise. A program
introductory letter and educational toolkit were
mailed to bariatric surgery specialists.
The program focuses on improving clinical
outcomes by managing co-morbid conditions and
dialysis-related issues. Of the patients currently in
the program:
• Average age is 68.7
• 56% have diabetes
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Annual Update 2006
ConnectionsSM Health Management Programs
8
• 70% have three or more co-morbid conditions
• Hypertension and diabetes are the two most
prevalent co-morbid conditions
• Infection is the cause of most hospitalizations
The HCS’s clinical-data review includes evaluation
of many aspects of ESRD management, including
the indicators below.
Connections Kidney Program Quality Care
Committee
The CKP Quality Care Committee is a group of
12 local network nephrologists who meet quarterly
to review the latest CKP program outcomes data.
The committee met four times this year, reviewed
data at an aggregate level, and advised on program
outreach priorities. Discussion focuses on spotting
trends and recommending areas for improvement.
Results are compared with benchmarks established
by the National Kidney Foundation/Kidney Disease
Outcomes Quality Initiative and the United States
Renal Data Systems/Regional Renal Networks.
Physicians interested in learning more about
the CKP, who would like to refer a patient to
the program, or who are interested in the
CKP Quality of Care Committee, can call
(866) 303-4CKP [4257].
ConnectionsSM Kidney Program Clinical Indicators
Condition
What is measured
Why is it important
This indicator measures whether
a monthly hemodialysis (HD)
assessment of the “delivered dose of
dialysis” was obtained, and if it is
at the desired level. The minimum
goal based on ESRD clinical practice
guidelines are a Kt/V of 1.2 HD or 2.0
peritoneal dialysis (PD) and a mean
urea reduction ratio (URR) >65%.
The delivered dose of dialysis is a
significant predictor of mortality
and hospitalization in HD and PD
patients.
Anemia Management
Hemoglobin (Hb) is measured as a
primary indicator of successful anemia
management. The minimal goal based
on clinical practice guidelines is Hb of
at least 11 g/dL.
Anemia is a major contributor to
mortality, hospitalization, and poor
quality of life in dialysis patients.
When anemia is controlled to
the levels listed, the outcomes are
improved. In addition, anemia
management can be optimized by
appropriately balancing the use of
Epoetin Alfa (EPO) and iron.
Bone Disease Evaluation
Calcium, phosphorus, calciumphosphorus product, and parathyroid
hormone (PTH) are measured, all of
which are reflections of the state of
metabolic bone disease in patients
on dialysis. Target values include a
corrected total calcium level preferably
toward the lower end of 8.4 to 9.5
mg/dL, phosphorus <5.5 mg/dL, and
a product of the two <55.
Bone disease in dialysis patients is
a major source of morbidity, with
bone pain and fractures common. In
addition, a high calcium-phosphorus
product leads to vascular and soft
tissue calcification.
Dialysis Adequacy
Why is it important
Pre-dialysis systolic and diastolic blood
pressure and pulse pressure (SBP
– DBP) are measured as indications of
overall blood pressure control. There
are no clinical practice guidelines in
this area, but optimal blood pressure
control would be a predialysis blood
pressure of <140/90 mm/Hg.
Hypertension is highly prevalent
in the dialysis population and is a
major contributor to morbidity and
mortality, particularly related to
cardiovascular and cerebrovascular
disease.
Diabetes Management
The prevalence of diabetes and the
level of glucose control is measured,
based on hemoglobin A1C. Adherence
with other aspects of diabetes
management based on public sector
clinical guidelines for retinal and foot
exams/wounds will be measured on an
annual basis.
Diabetic patients with poor
glucose control are more likely to
experience increased morbidity
and microvascular complications
of diabetes, increased mortality,
less energy, and poor quality of
life. Close monitoring of blood
sugars leads to improved control of
diabetes and lessens the likelihood
of progression of other diabetic
complications. Monitoring for
retinopathy and foot disease/wounds
will permit early intervention to
minimize these complications.
Cardiac Management
Annual LDL measurement and the
LDL level achieved are reviewed.
In addition, there is tracking of
whether patients are being treated
with angiotensin converting enzyme
inhibitors (ACEIs), angiotensin
receptor blockers (ARBs), or beta
blockers for appropriate indications.
Cardiovascular disease is the most
frequent cause of death in dialysis
patients, with a prevalence of
coronary artery disease 5 to 30
times that of an age/gender matched
population without kidney disease.
The prevalence of left ventricle
hypertrophy is also much higher in
dialysis patients.
Vascular Access
Management
This indicator tracks the type of
vascular access that is being used
overall and for diabetics. Access
types for HD include the natural
arteriovenous fistula (preferred), the
graft arteriovenous fistula, and the
percutaneous catheter (least desirable).
For PD, the access is the peritoneal
catheter.
Vascular access is one of the key
determinants of hospitalization
in HD patients, with significantly
better outcomes if a natural
arteriovenous fistula is used.
Percutaneous catheters are associated
with infection/sepsis/death, and
should be avoided whenever possible.
In PD patients, the PD catheter is a
major source of infection and other
complications.
Blood Pressure
Monitoring
Annual Update 2006
What is measured
ConnectionsSM Health Management Programs
Condition
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Annual Update 2006
ConnectionsSM Health Management Programs
Condition
Hospital Admissions
What is measured
Hospital admissions, hospital days,
average length of stay, and skillednursing bed days are measured.
ConnectionsSM
AccordantCare™ Program
In 2005, we expanded the Connections
AccordantCare Program to our Connections
Programs throughout the family of companies,
through a partnership with Accordant Health
Services, a specialized disease management
organization. More than 1.5 million members in
the Plans are eligible for the program.
On December 1, 2006, Crohn’s Disease was
added to the list of chronic, complex diseases
managed through the Connections AccordantCare
Program. Like the other 15 diseases covered by the
Connections AccordantCare Program (Accordant),
Crohn’s disease has a similar complexity, affects a
significant segment of the membership, and has
complications that respond to medical interventions,
especially if reported early. With the addition of
Crohn’s disease, as with the other diseases already in
the program, Accordant will continue to focus on
educating members about their disease, including
the importance of reporting symptoms to their
doctor and adherence to treatment and medication
therapies.
The ConnectionsSM AccordantCareTM Program
provides resources to help you manage your
AmeriHealth patients with 16 complex chronic
conditions. The goal of the program is to work
with you to improve the clinical outcomes of these
patients. As with all of our disease management
programs, this does not change your relationship
with us or your patients. This program is designed to
improve patients’ compliance and self-management
skills, and to support your treatment plans.
10
Why is it important
These are major indicators of clinical
outcomes and resource utilization
that should be modifiable with
effective disease management.
More than 11,000 members are participating in
the ConnectionsSM AccordantCareTM Program as of
September 30, 2006. Fifty-eight percent participate
at an “interactive status” (active communication
with a disease management nurse and completion
of quarterly assessments). While disease-specific
mailings and web access are available to all
participants, 42 percent of the participants chose
to use the web libraries and to receive mailings
only. Most eligible members choose to participate,
but 6.41 percent of members who are eligible to
participate in the program opt out when contacted.
Program Diseases
Seizure Disorders, Rheumatoid Arthritis,
Multiple Sclerosis, Crohn’s Disease, Parkinson’s
Disease, Systemic Lupus Erythematosus (SLE),
Myasthenia Gravis, Sickle Cell Disease, Cystic
Fibrosis, Hemophilia, Scleroderma, Polymyositis,
Chronic Inflammatory Demyelinating
Polyradiculoneuropathy (CIDP), Amyotrophic
Lateral Sclerosis (ALS), Dermatomyositis, and
Gaucher Disease.
The Connections AccordantCare Program assists
providers by:
• Answering calls from patients with questions
about their condition 24-hours-a-day.
• Educating your patients through Accordant’s
informative website (www.accordant.com),
monthly newsletters, and contact with nurses.
Accordant helps your patients understand their
condition, find support, and provide other
useful resources.
• Improving patient compliance with your
prescribed treatment plan through education
• Providing you with access to Accordant’s
nationally recognized medical advisers who
are available to discuss complex patient or
treatment issues at no cost to you.
• Coordinating care among all members of the
patient’s health care team. Accordant can assist
you with the time-consuming “leg work” often
necessary for patients with complex, chronic
diseases.
For more information, visit the Accordant website
at www.accordant.com. If you have questions, call
the ConnectionsSM AccordantCareTM Program at
(866) 398-8761, 8 a.m. to 9 p.m., Monday through
Thursday, and 8 a.m. to 5 p.m. on Friday, Eastern
standard time. Messages left after hours will be
returned the next business day.
Clinical Practice Guidelines
and Clinical Insights
Updated Clinical Practice Guidelines were mailed in
October 2006. The Guidelines and issues of Clinical
Insights can be found on www.amerihealth.com/
providers or by calling (800) 858-4728.
The Clinical Practice Guideline Grid, which
includes all AmeriHealth Clinical Practice
Guidelines with reference information and source
URLs (when available), was updated and includes
guidelines on the following topics: CAD, CHF,
COPD, diabetes, end-stage renal disease, the
complex chronic diseases managed by Accordant
Health (listed within the grid), hyperlipidemia,
hypertension, immunizations (adult and child),
Clinical Practice Guidelines are a generally accepted
minimum standard of care in the medical profession.
Adherence to these guidelines may lead to improved
patient outcomes. Individual clinical decisions
should be tailored to specific patient medical
and psychosocial needs. As national guideline
recommendations evolve, please update your practice
accordingly.
AmeriHealth updates our guidelines annually based
on changes made to nationally recognized sources.
Changes are reviewed by internal and external
consultants as appropriate, as well as by plan
quality committees, and are incorporated into the
guidelines.
The guidelines are not a statement of benefits.
Benefits may vary based on state requirements,
product line (HMO, PPO, etc.), or employer group.
Individual member coverage will need to be verified
with us. If you have any questions or concerns
regarding member coverage, or if you would like
more information on specific benefits coverage,
please contact Provider Services at (215) 567-3590
or (800) 227-3119* for HMO coverage and (215)
567-3694 or (800) 332-2566* for PPO coverage.
You may access the Clinical Practice Guidelines
on our website at www.amerihealth.com/providers,
or you may call the Provider Supply Line at
(800) 858-4728 to obtain a printed copy of the
guideline grid or of any of the individual guidelines.
Annual Update 2006
• Conducting routine preventive health
evaluations with your patients via telephone
or email, to detect early warning signs of
complications. Accordant monitors subtle
changes in your patients’ condition and alerts
you to changes that require follow-up.
obesity, preventive health, tobacco cessation,
attention deficit activity disorder, depression,
schizophrenia, substance-use disorder, and suicide.
ConnectionsSM Health Management Programs
to the patient and notifying you of pertinent
changes in your patients’ health. Accordant
supports your treatment objectives and works
closely with your patients to ensure compliance.
In addition to our guidelines, we offer provider
Clinical Insights. These documents are summaries
of the key points in the ConnectionsSM Health
Management Program. Currently available are
the 2006 Clinical Insights, covering the following
conditions: asthma, CAD, CHF, COPD, and
diabetes. You can download a copy of the Insights on
our website, or you can obtain a printed copy via the
Provider Supply Line at (800) 858-4728.
* Outside the 215 area code
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