BCBS Michigan Case Study

Measuring & Improving the Effectiveness of Wellness, Disease & Care Management Teams: A BCBS of Michigan Case Study

Blake Andersen, PhDHealthSciences Institute

Michelle Fullerton, RN, CCM, CCP Blue Cross Blue Shield of Michigan

• A learning and networking community for all professionals serving people at risk of, or affected, by chronic conditions.

• Supporting health coaching and chronic care improvement practices that deliver best value to patients and purchasers.

• Offering free, noncommercial skill‐building webinars through the PartnersinImprovement alliance.

• Facilitated by HealthSciences Institute and sustained by individual members and partner organizations.

Agenda

10:30 to 11:30 (CT) Learning Presentation & Discussion

11:30 to 11:45 (CT) Learning Collaborative Community Call

Measuring & Improving the Effectiveness of Wellness, Disease & Care Management Teams: A BCBS of Michigan Case Study

Blake Andersen, PhDHealthSciences Institute

Michelle Fullerton, RN, CCM, CCP Blue Cross Blue Shield of Michigan

www.healthsciences.org

• Summarize why developing and measuring staff proficiency in MI is key to better program outcomes.

• Discover why most MI training programs often fail to deliver expected results.

• Detail a best practice approach for building staff proficiency in chronic care and MI.

• Describe how the Health Coaching Performance Assessment (HCPA) is being used to benchmark and improve performance.

• Share practical steps for addressing staff, operational and administrative barriers to program performance improvement.

Learning Objectives


Realizing the Promise of Wellness, Disease Management & Care Management


Questions Our Customers Are Now Asking in RFPs & RFIs for Wellness, Disease Management & Care Management Services • Can you describe your wellness, disease management, care management or health coaching behavioral intervention?

• Are your staff proficient in best practice methods proven to deliver better engagement and clinical/cost outcomes?

• Do you use a standardized process to measure service quality?

• What is your process for continuous performance improvement?

• What are you doing that is different or better than other health plans, providers or vendors offering these services?


• Outsource and/or insource

• Program reorganization/integration

• New methods/metrics for assessing impact/return on investment (ROI)

• Member/patient engagement or participation incentives

• Steps to improve staff productivity or call center performance

• Non‐nurse health coaches, e.g., social workers or lay coaches

• Information technology (IT)

• New predictive modeling or analytics

• Service technologies, e.g., robo calls, IVR, telehealth/monitoring

• New service sites (workplace, health plan, primary care/medical homes)

• Program accreditation (URAC/NCQA)

• Call monitoring or quality assurance

• Telemarketing training

• Pop‐psychology health coaching

• Motivational interviewing training

Strategies Programs Have Used to Improve Wellness, Disease Management & Care Management Outcomes


How Can We Best Address the Main Causes of Poor Health, Disability and Avoidable Health Care Costs?

What’s Driving Health Care Costs?

How Can We Reduce These Costs?

How Well Are We Applying Proven Approaches?

Chronic diseases account for 75% of direct costs and most disability.

Chronic care is a new practice model that requires new approaches and workforce competencies.*

• Are staff proficient in these new approaches?

• Are staff routinely using these approaches?

• Are we objectively measuring the quality and effectiveness of services?

85% of avoidable costs are due to behavioral not medical factors.

Best practice, brief health coaching approaches deliver better patient‐level results in 300+ rigorous clinical trials.

*Institute of Medicine, World Health Organization, et al.


Better Results Require Best Practice Services and Best Practice Management Strategies

“We won’t get better health care value without greater integration of evidence‐based medicine and evidence‐based management."

Stephen Shortell, PhD, Professor & Dean School of

Public Health at the University of California‐Berkeley

• Reduce variance in the quality and effectiveness of the services delivered

• Replace topical CE and legacy training with best practice learning approaches

• Measure staff proficiency in best practice services and solutions

• Continuously measure and improve the effectiveness of services through validated, objective methods/tools.


BCBSM Case Study: Making Excellence in Health Coaching

a Market Differentiator


• Blue Cross Blue Shield of Michigan (BCBSM) overview

• The current health plan/health care marketplace

• What we’ve tried to date, including traditional motivational interviewing (MI) training programs

• Our rationale for a new approach:− Chronic Care Professional (CCP) certification − Advanced learning strategy to build MI skills− Evaluating return on investment (ROI) for our organization− Measuring results that matter most to customers

Why Did BCBS of Michigan Invest in This Program?


Benchmark Measure Results Improve Benchmark Measure Results Improve

Ongoing CE & Resources (30+ hrs)

Case Review: Skills Application & Learning Transfer (1 hr per mo)

Mentor Development Program (1 hr Team/.5 hr indv per mo)

BCBSM Implementation Timeline (2011)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2‐Day MI Workshop

CCP Core Program & Exam (40 hr)

HCPA Q1Pre

HCPAQ2

HCPAQ3

HCPAQ4Post

Mentor Selection


• Build 21st Century workforce competencies recommended by the Institute of Medicine and validated in numerous studies.

• Only nationally‐recognized health coaching/chronic care learning and certification program (online program).

• An award‐winning, advanced learning program that combines a 40‐hour CE‐approved core curriculum & exam.

• Linked with better clinical/cost outcomes in organization evaluations and reviews.

• Maximizes focus and impact of health coach specialist onsite program, case review and other learning components.

• Supplemented by 30+ CE hours/resources (largest MI online video library; monthly archived webinars and materials).

1. Chronic Care Professional (CCP) Learning & CertificationBuild Required Chronic Care & Health Coaching Competencies


1. Health Care Performance Improvement

2. Population Health Improvement Solutions

3. Chronic Diseases & Age‐Related Conditions

4. The Partnership Model of Care

5. Health Behavior Change Facilitation

6. Health Promotion & Coaching

Chronic Care Professional (CCP): Curriculum Overview


The CCP Process: Build Core Competencies, Complete Examination, Access Ongoing CE and Learning Tools

• Build foundational chronic care and health coaching best practice skills & knowledge

1. CCP Core Curriculum1. CCP Core Curriculum

• Test knowledge via standardized, validated exam (required for national certification)

2. CCP Exam & Certification2. CCP Exam & Certification • Access CCP member

monthly webinars/ archives and tools; MI video skill‐building library

3. Ongoing Skill‐Building3. Ongoing Skill‐Building

Up to 12 Months Ongoing


• Intensive two‐day program facilitated by MINT specialists in health coaching and chronic care.

• Builds on MI content and job tools from the Chronic Care Professional (CCP) program.

• Delivered on‐site to teams of 50 or more staff (per session).

• Action learning‐based program that includes individual and team practice in MI approaches for better engagement, adherence, self‐care and lifestyle management coaching.

• Specially designed for wellness, disease/care management program populations and challenges.

• Training materials and resources included.

2. Motivational Interviewing (MI) Onsite Immersion TrainingDevelop MI‐Based Health Coach Specialist Competencies


Health Coaching: Defining the Best Practice

Traditional Patient

Education Models

Popular Health (Life) Coaching Models

Based on life coaching, pop‐psychology or single studies

Best for motivated, verbalpatients from Western cultures

Ineffective health coaching approach for most patients

Brief and Effective Health Coaching

Must work for all patients, particularly the most “resistant”

Must blend clinical expertise with patient centered approach

Based on the acute, paternal model of medical care

Seems quick and productive; outcomes‐focused (clinician’s)

Not generally efficient in clinical practice; not outcomes focused

Must be efficient, productive and behavior change‐oriented

Legacy style of education; most simple to learn and practice

Lack of standards to teach, measure or improve proficiency

Standards to teach, measure and improve proficiency

Motivational Interviewing (MI)‐Based Health Coaching


• Motivational Interviewing (MI) is the only health coaching approach to be fully described and consistently demonstrated as causally and independently associated with positive behavioral outcomes (Butterworth, Linden, McClay, 2008)

• Over 300 clinical trials demonstrate its efficacy (www.motivationalinterview.net)

• Standardized methods of delivery, training and coding tools exist to assess fidelity

Best Practice in Health Coaching


• Resistance is correlated with negative clinical outcomes

Behavior Change Research

• Change talk is correlated with positive clinical outcomes

The best case scenario is one in which the provider is evoking change talk from the patient.

The worst case scenario is one in which the

provider is arguing for the change while the patient

argues against it.


• All change talk is positive –while commitment language may be better, both correlate with positive clinical outcomes

• MIC evokes more change talk, while MIIN results in more counterchange talk

• Variables comprising MI Spirit do not alone appear to account for MI’s effectiveness, but may increase engagement and change talk

Behavior Change Research

“[Practitioners] who wish to see more change talk should selectively reflect the change talk they hear and provide fewer reflections for counterchange talk. What [practitioners] reflect, they will hear more of.“

Moyers et al., 2009


Learning MI

“Watch a skillful clinician providing MI, and it looks like a smoothly flowing conversation in which the client happens to become increasingly motivated for change. In actual practice, MI involves quite a complex set of skills that are used flexibly, responding to moment‐to‐moment changes in what the client says. Learning MI is rather like learning to play a complex sport or a musical instrument.”

Miller & Rollnick(2009) p. 135


Why Do Motivational Interviewing Training Programs Often Fail to Meet Expectations or Deliver ROI?

Internal or external motivational interviewing (MI) training workshop(s)

Internal or external motivational interviewing (MI) training workshop(s)

Learning transfer?Evaluation of assessment tool or scripts?Improvement leadership and culture change?

Learning transfer?Evaluation of assessment tool or scripts?Improvement leadership and culture change?

Measurement of staff proficiency?Assessment of program effectiveness?Staff/leadership reporting?

Measurement of staff proficiency?Assessment of program effectiveness?Staff/leadership reporting?

“Our staff are using MI,” or, “Our staff are notusing MI,” or, “We’re not sure what our staff are using”What is the return on this investment (ROI)?

“Our staff are using MI,” or, “Our staff are notusing MI,” or, “We’re not sure what our staff are using”What is the return on this investment (ROI)?

Best practices in management, strategic human resources, learning and development, organization development AND Motivational Interviewing?


• Monthly phone‐based sessions led by HealthSciences MINT health care experts; limited to 12‐15 staff each.

• Sustains momentum in 30 to 60 day post‐training period (when usual training program results begin to fade).

• Supports practice, transfer and application of CCP and MI workshop skills to daily job roles.

• Include monthly lesson plans with focus on building skills, applying MI on the job—targeting service populations.

• Facilitator(s) and team members explore MI steps for addressing engagement and change barriers.

3. Monthly Team Case Review SessionsSupport MI Skills Transfer & Application to the Job


• Familiarity with the “MI spirit,” MI concepts or MI techniques does not equate to MI proficiency.

• Self‐assessed proficiency in MI is statistically unrelated to actual proficiency in MI when measured with a validated, standardized tool.

• In the 300+ studies demonstrating the impact of MI, MI was the intervention.

• MI proficiency requires immersion training, application support and personal feedback using a validated, standardized tool.

• Measurement of fidelity to MI is required to realize outcomes shown in MI clinical trials.

Confusion About “Knowing” and “Doing” MI: The MI Fidelity Problem

We do MI


• Advanced tool and web‐based performance measurement/management system (patent pending).

• Measures staff proficiency in key practitioner and patient behaviors empirically linked with behavior change.

• Individual reports provide summary scores, specialist/ expert comparisons and skill‐building recommendations.

• Group reports provide leaders with aggregate summary scores, time comparisons and improvement suggestions.

• High inter‐rater reliability and criterion validity (compared to MITI) in an external evaluation by Linden & Associates.

• Measures ROI of HealthSciences Institute’s programs.

4. Health Coaching Performance Assessment™ Measure & Report Effectiveness in MI‐Based Health Coaching


Section 1: HCPA Summary Scores

Level of MI adherence, MI global characteristics, use of open‐ended

questions, reflections, change talk, etc.

Section 2: Missed Opportunities

Opportunities for exploring and addressing ambivalence, building change motivation,

agenda setting, action planning, etc.

Section 3: Strengths of Health Coaching Session

Examples of effective health coaching strategies used by the health coach that

support health behavior change.

Section 4: Recommendations for Health Coaching Skill‐Building

Summary of practical steps that the health coach can take to build health coaching

proficiency and effectiveness.

Overview of the Individual HCPA Report


Overview of the HCPA Measurement & Performance Improvement Process

4. Report – Individual and group reports delivered to staff/leaders

5. Improve – Improvement steps prioritized and implemented

6. Reassess – Progress/ROI assessed, ID new improvement steps

3. Analyze – Data evaluated and improvement feedback provided

2. Code – Samples evaluated by HCPA‐certified coder

1. Sample – Audio recordings extracted/encounters sampled


• HCPA Training Prerequisites & Approval− Demonstrated proficiency in motivational interviewing documented by recent MITI, MISC or HCPA report

− Completion of MITI training program

• HCPA Certification Training Program & Proficiency Exam − Application and/or faculty approval− Four‐hour webinar‐based training series − Proficiency assessment using HCPA on actual sample− Individual mentoring session (as needed) − Training, assessment and certification fee ($350)

HCPA Coder Certification Requirements


• Mentors selected based on HCPA performance, interest and leadership approval (1:10 mentor/staff ratio).

• Monthly mentor team/leadership session that support development of internal mentor program.

• Individual mentor skill‐building sessions with HealthSciences MINT health coaching specialists, to support MI skill‐building and mentoring skills.

• Mentors gradually take ownership of case review sessions and individual staff coaching moving forward.

• HealthSciences provides access to CCP, MI workshop and HCPA for new and existing staff in year two and beyond.

5. Mentor Skill‐Building Program Select and Develop a Team of Internal Mentors


Blue Cross Blue Shield of Michigan (BCBSM) Outcomes Evaluation


• “I have to say I was one of the skeptics and did not think it would work, but when I ask open ended questions, I am surprised how well it works. I am an MI convert.”

• “When I ask permission before giving advice, patients seem to relax and be more involved – it’s sort of like I am putting them in control.”

• “When I summarize what has occurred during the call, if I miss something, the patient tells me what I left out. Then, I ask them what the next step is and it really gets them thinking about what they can do.”

• “When I go back and listen to a call from before the training, I realize how different my approach is now.”

The Nurses’ Perspective:Making the Transition


BCBSM HCPA Pre and Post Aggregate Reports: (Q1 to Q2 Comparison)

MI Adherence: Percentage of techniques consistent with MI vs. MI non consistent approaches

Q1 Q261% 71%

Target goal = 90%

Example (Pre):“Mr. Jones, you really need to get those A1Cs under control or you will really start to see some nasty consequences!”

Example (Post):“Mr. Jones, I know you’ve had diabetes for a long time and know a lot about it. What do you know about A1C values and what do they tell you about your condition?”



Resisting the Righting Reflex: Avoiding the need to jump in and fix the patient’s behavior which tends to elicit “resistance”

Q1 Q22.6 3.3

Target goal = >4

Example (Pre):“It’s important for you to avoid those fatty foods. Have you tried staying away from fast food restaurants and packing your own lunch instead?”

Example (Post):“Sounds like [from what pt just said] that you really see the importance of cutting down some on fatty foods. How do you think you could go about doing that?”



Evoking/Exploring the Patient’s Motivation for ChangeEliciting reasons for change from patient vs. telling them why they should change

Q1 Q22.3 2.9

Target goal = >4

Example (Pre):“It’s important for you to avoid those fatty foods. Have you tried staying away from fast food restaurants and packing your own lunch instead?”

Example (Post):“Sounds like [from what patient just said] that you really see the importance of cutting down some on fatty foods. How do you think you could go about doing that?”


• Requires an integrated approach including marketing materials, incentives and best practice health coaching skills

• To date, engagement improvement efforts have focused more on incentives and marketing, less on engagement skills.

• Engagement is a process, entailing several stages− Enroll in program (opt‐in/opt‐out?)− Number of calls (optimal number?)− Program completed (how is completion defined?)− Goals attained (how are goals set/completion defined?)

Defining “Engagement”


What’s the Cost of Poor Engagement to Our Customers?

7%7% 29%29%

*2011 pilot study: Large Northwest US grocery retailer targeting high‐risk employees

300% Increase in Enrollment

A missed opportunity to: • Encourage receipt of evidence‐based medical care by providers • Assist with conditions, medications and or other concerns

AND• Support critical short/long‐term self‐care, adherence or lifestyle changes

Usual Practice: Previous results from enrollment specialists

Better Practice: Engagement rate by HealthSciences Institute staff‐trained specialists (same population & program)*


• BCBSM Engagement Study− Team includes HealthSciences Institute and BCBSM staff, external evaluator (Linden Consulting Group)

− Will objectively assess the impact of the health coaching improvement program on various engagement measures

− Define BCBSM and industry options for better engagement

• Enrollment Specialist Program − MI‐based training and certification program

• Collateral Review & Development− Review of enrollment marketing materials, scripts, etc.

Assessing & Improving Engagement at BCBSM


• Steps for promoting leadership buy‐in and support

• Incorporating MI into existing scripts and assessments

• Supporting staff transition to this new model & culture change

• Communicating the value of this program to our customers

Leadership & Organization Perspective: Making the Transition


• Most human and financial health care costs are due to chronic conditions and patient health‐related behaviors.

• There are highly effective approaches for improving patient engagement and health‐related behavior change.

• These best practice approaches are not routinely used in most wellness, health coaching, disease management and care management programs.

• By building and measuring staff proficiency in best practice health coaching approaches, proficiency and effectiveness can be improved.

• Measuring staff and program effectiveness, provides organizations with a pathway for managing and improving results.

• Excellence in reducing avoidable health care costs is the key to success for all wellness, disease management and care management programs.

Conclusions

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Upcoming Learning Collaborative Events

Date Topic Presenter

Sept 9Transitional Care Model: Translating Research Into Practice & Policy

Mary Naylor, PhD, RN, Professor of Gerontology, Director,NewCourtland Center for Transitions & Health, School of Nursing, U of Pennsylvania

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Learning CollaborativeCommunity Call

Learning Collaborative Community Call

• 2011 PHI Learning Collaborative meeting planning• Case studies and best practices in wellness, disease

management and care management • Health Coaching Performance Assessment (HCPA)

– White paper & FAQ document– Updates: www.HealthSciences.org/HCPA

• HCPA Certification Program (October 10th & 24th)• CCP Certification Recognition

Documents

BCBS Michigan Case Study