By Angel Strange, LMSW, Business Change Manager, Anthem, Inc

CMSA Foundation - 2020 Case Management Practice Improvement Award Recipient

Case manager Margo Gordon found herself in a Tennessee emergency room last year. It wasn’t the first time she had been there to help a member of a Medicaid health plan, operated by an affiliated plan of Anthem Inc., but she’s hopeful a new program will make it less frequent. The member, who Gordon had been working with for two months, had been diagnosed with schizophrenia and had suffered a psychotic breakdown. Gordon became aware the member was in the ER when she saw her name on the hospital ER admission list. Gordon’s health plan monitors the list for its High Outreach to Promote Engagement – or HOPE – a program created for the health plan’s most vulnerable populations to improve member outcomes and lower health care costs by anticipating and supporting member’s needs before and after they need medical help.

“I spoke with her to make sure she knows someone was looking after her,” Gordon said. “And she began to cry. No one knew where she was. She was very emotional about me being there with her….Going out and meeting with members opens up a different level of trust and it establishes a relationship and the member can feel like they can trust you and that you are there for them,” Gordon said.  “You become real to them and they can reach out to you. You are developing that relationship for when they need someone the most.”

Today, the member’s son is back living with her, and she has a positive relationship with her family. She is taking her medications on schedule and has a job. She also hasn’t been admitted to the hospital since the psychotic event in 2019.

Anthem created HOPE in 2018 to meet the needs of the most complex members – those with the highest rates of multiple chronic conditions and higher than average ER and inpatient admissions for both behavioral health and physical health. HOPE’s case managers are licensed clinicians, serving as the central point of contact responsible for supporting all aspects of services and supports, regardless of diagnosis. This allows for a stronger relationship with members by encouraging direct interaction with the same person consistently. Members also work closely with other staff, who are certified peer support specialists, and have personally experienced a mental illness or a substance use disorder. From HOPE’s inception in 2018 until May 2020, Anthem-affiliated health plans had 3,533 members referred to the program with a 69 percent engagement rate. This includes members in Anthem’s Medicaid, Federal Employee Program, employer-sponsored, individual, and Medicare health plans. This work included interacting with 2,500 providers. As a result, emergency room and in-patient hospitalization decreased on average by 50 percent. About 30 licensed clinicians provide this support. For this work, the HOPE program was recognized by the Case Management Society of America’s Foundation with the 2020 Case Management Practice Improvement award.

Case managers help members understand their healthcare, including how to take medication, and help them to follow up on appointments and their care. Often, HOPE case managers bridge the gap for members as they are leaving the hospital as they may have received new medications in the hospital and are unsure if they should continue to take their old medication or how to follow up for their next doctor or home health visit. Sometimes they go to appointments with members and sometimes they help members find transportation to appointments. Case managers often assist members in finding community resources they may not have known about. However, this year COVID-19 has restricted how often case managers can be in the field. A process to meet with members virtually through videoconferencing has been established for those members who can take advantage of it.

“They need to know they have someone who advocates for them and someone who will provide for them those resources they have not been able to connect with,” said Linsey Langmo, one of the managers of the HOPE program. “Often, they don’t know what’s available to them – either from insurance benefits or community resources. They need a supporter and we can be that for them.”

Click here to read the complete article in CMSA Today.