AHM Medical Management: Self-Care and Decision Support Programs

Objectives:
After completing the lesson Self-Care and Decision Support Programs, you should be able to:
Describe the use of telephone triage services in self-care and decision support programs
Identify some general methods that health plans can use to evaluate the effectiveness of
their preventive care, self-care, and decision support programs
Discuss the use of integration and partnerships to improve preventive care, self-care, and
decision support programs
Introduction
In the lesson Preventive Care Programs, we described how health plans use preventive care
programs to achieve better overall health for health plan members. In this lesson, we describe the
use of self-care and decision support programs. Self-care programs focus on providing members
with the knowledge and confidence to perform certain aspects of healthcare for themselves.
Decision support programs enable members to (1) decide when and how to seek medical care
from healthcare professionals and (2) participate with providers in decisions about the course of
care. At the end of the lesson, we explore some general strategies that health plans may apply to
all of these programs, including considerations for program evaluation.
Self-Care Programs
Most health plan members experience some type of healthcare problem on a regular, even daily,
basis. In many instances, these medical problems are minor ones-headaches, indigestion, cuts,
scrapes, colds, and muscle aches, for example-that members generally treat without the assistance
of healthcare professionals. However, without appropriate treatment, these conditions may cause
pain or worsen to the point where professional care is necessary. For example, a small cut that is
not kept clean may become infected and require treatment with antibiotics or even surgery. Many
health plans offer self-care education and training to enable members to assess healthcare
problems and, when appropriate, take care of the condition on their own.
Types of Self-Care Programs
Self-care programs typically address common symptoms, illnesses, and injuries that can usually
be safely and effectively treated with readily available methods such as rest, changes in diet,
over-the-counter medications, or applications of heat or cold. Self-care education also helps
members differentiate between minor problems and serious conditions that require treatment by
healthcare professionals. Insight 4B-1 provides an example of self-care instruction that might be
distributed to members. Some self-care initiatives teach members to conduct breast or testicular
self-examinations, skin cancer checks, blood pressure monitoring, and other screening tests.
Health plans often combine self-care programs with preventive care and telephone triage
programs.
Some health plans also have self-care programs for members with chronic conditions that require
regular management in order to prevent pain, complications, or hastening of the disease process.
Severe arthritis and diabetes are two examples of common illnesses that need proper daily care by

members in addition to services from providers. This type of self-care is often included in a
health plan's disease management programs.

Another application of self-care education is for members who need ongoing care because they
are recovering from acute illnesses or injuries. Proper self-care for these members can speed
recovery and reduce the likelihood of complications. For example, a member's progress in
recovering from a heart attack depends in great part on how well the member complies with
provider recommendations on medications, diet, and exercise. A self-care program that focuses
on cardiac rehabilitation can enhance the member's understanding of the instructions and
confidence in performing self-care.
Methods of Delivering Self-Care Information
Health plans use a variety of approaches to convey self-care education and training to members.
Common methods include member newsletters, self-care pamphlets and books, recorded

messages that are accessible by telephone, videotapes, information on the health plan's Internet
website, references to other relevant websites, and interactive computer programs.
The criteria for selecting an appropriate medium for conveying self-care information are similar
to those described for health promotion programs. Since the information provides advice on
medical care, all material must be clinically sound according to current standards to promote
proper treatment and to protect the health plan from charges of negligent care. In addition, the
presentation of the material should be understandable by the average layperson.
While health plans often distribute some self-care information to all members, they may wish to
target some members for additional education. The health plan can check claims and encounter
reports to identify members with records of inappropriate utilization of medical care.
Demographic information may also be useful in identifying members with high potential for
experiencing illness or injury and creating programs to address their needs. For example, families
with young children tend to visit providers frequently, many times for health problems that could
be treated by parents if they knew the proper approach. Health plans can send them self-care
information about common children's illnesses and injuries and refer them to telephone triage
lines or Internet websites for additional information. Health plans may also design self-care
information for women, men, teenagers, senior citizens, or other demographic groups. 1
Member Participation
When designing and promoting their self-care programs, health plan medical management
personnel must realize that members vary greatly in terms of their perceptions of need for
healthcare services from providers and their readiness to adopt self-care. Members who visit
providers for seemingly minor problems because they lack the knowledge or self-confidence to
perform self-care are often receptive to self-care instruction. Other members would rather see a
provider because they consider self-care too much trouble or they enjoy the attention they receive
from providers and their staffs. These members may need extensive education and motivation
before they will attempt self-care, and in many cases, the results may not justify the expenditure
of health plan resources.
Decision Support Programs
Decision support services are another approach that health plans use to give members more
control over their own health. Members often seek care that is unlikely to improve their health
because they lack the knowledge to choose the healthcare services that are the most appropriate
for their situations. Health plans can improve member's abilities to make appropriate care
decisions through educational material and advice from healthcare professionals about specific
medical problems. Telephone triage and shared decision making are the most common types of
decision support programs used by health plans.
Telephone Triage Programs
When medical problems occur, many consumers have difficulty judging (1) whether to seek
professional healthcare services and (2) what type of services they should seek. For example, a
member may wonder if a child's sore throat is really a symptom of something more serious, such
as a streptococcus infection (strep throat). When members experience troubling symptoms,
telephone triage programs can help them determine the most appropriate approach to care.

Telephone triage programs are phone-based services with clinical staff who provide information
to sick or injured members to help the members decide if they need to seek care immediately at
an emergency department or urgent care center, call a provider for an appointment, or treat the
condition themselves. When a situation is urgent, the staff can alert the local emergency
department or urgent care center of the member's needs and impending arrival. If self-care is
indicated, the clinician can instruct the member on self-care treatments to relieve symptoms and
hasten recovery. The staff may also be able to authorize referrals for specialty care and expedite
appointments with specialists if the condition warrants specialty care. Figure 4B-1 provides an
example of the health problems that most frequently caused the members of one health plan to
call the plan's telephone triage line.

Telephone triage service is generally available at a toll-free number during hours well beyond
typical PCP office hours. In many cases, telephone triage service is offered 24 hours a day, 7 days
a week, 365 days a year. Plans that have telephone triage in addition to self-care or health
promotion programs may integrate some or all of these services at a central call center.
The clinical staff at telephone triage services are typically nurses or physician's assistants who
have been trained specifically for this type of healthcare service. A physician with relevant
clinical experience and training in managing phone triage lines generally oversees the
development and implementation of the program. The clinical staff are often assisted by

nonclinical personnel who answer calls, obtain nonmedical data (such as health plan membership
information), and route the calls to the clinical staff.
When a member calls with a medical problem, the clinical staff person listens to the caller's
explanation of the problem and then asks a series of questions about the situation to help the
caller determine the seriousness of the problem and the most appropriate course of action. For
risk management purposes, telephone triage clinical staff should not attempt to diagnose or give
medical advice. Training for staff should emphasize that their role is to elicit information about
symptoms and other aspects of the situation and then promptly refer emergencies to an
emergency department or explain treatment options for nonemergency needs.
Clinical staff members use clinical decision support tools to guide them in their questions and
responses to members. These decision support tools range from manual systems with different
patterns of questions based on a member's responses to interactive computer programs that
provide the clinical staff with information and questions suited to the situation. Regardless of the
level of technology used, clinical decision support tools should be evidence-based guidelines that
are developed in a manner similar to that for clinical practice guidelines (CPGs). The use of
scientifically sound decision support tools increases the likelihood of good clinical outcomes and
protects a health plan against charges of negligent care. Even though there may not be a physician
or pharmacist on location, the clinical staff should be able to contact these healthcare personnel
immediately if the decision support tool gives this direction or if a staff member feels that
additional input is indicated. For example, a clinical staff member who suspects that a member's
problem is due to drug interactions may wish to contact a pharmacist.
The clinical staff member documents all information received from and given to the caller,
including the type of care the caller plans to utilize and follow-up activities that the staff should
perform. Typical follow-up actions include
Expediting referrals and appointments with specialists
Relaying relevant information about the call to a member's PCP
Contacting the member and/or the provider from whom the member sought care to gather

outcomes information

Checking back periodically to reassess the situation when a member has decided that

self-care is the appropriate approach

Accurate, complete documentation of calls is critical for quality management. QM activities for
telephone triage typically focus on both the quality of clinical information provided and the
quality of service. For example, how did the information given affect the ultimate outcome of the
medical problem? Was the caller able to speak with a clinical staff member promptly?
Monitoring the reasons for calls to telephone triage services can also be useful to the health plan's
development of health promotion or self-care programs. Suppose that the telephone triage service
receives many calls regarding children with fevers. The health plan may decide to send self-care
information describing the treatment of fever in children and indications for seeking professional
care to members with children.
The full documentation of calls is also necessary for the protection of the health plan in case it is
faced with a legal suit that involves information given out by its telephone triage service.

URAC has an accreditation program specifically for telephone triage and health information
services. This accreditation program's standards address staffing, policies, and procedures for
handling calls, including the use of clinical decision support tools, documentation of calls, followup activities, and quality management.2
Even if a health plan does not seek accreditation from this agency, URAC's standards may be
useful quality guidelines for establishing and operating this type of program.
Delegation of Telephone Triage Services
Health plans often delegate telephone triage activities. Contracting with a delegate typically
allows a health plan to implement telephone triage more quickly than developing its own
program. Since this program is conducted by phone, the delegate does not need to be in the same
geographic area as a plan's members, so many telephone triage companies operate on a regional
basis and serve multiple health plans. As a result, health plans have many potential delegates to
choose from.
When a health plan delegates telephone triage, the health plan must confirm that the delegate
Understands the health plan's medical policy and is prepared to provide triage

information consistent with this policy

Employs qualified, well-trained clinical personnel

Uses evidence-based clinical decision support tools
Has an effective system for rapid feedback to PCPs and the health plan on a case-by-case

basis for emergencies

Benefits of Telephone Triage Programs
Telephone triage programs offer benefits for plan members, providers, and the health plan itself.
Members typically view telephone triage as a convenient, no-cost way to obtain healthcare
information. Receiving information from a healthcare professional can relieve anxiety for
members who have a condition that is beyond their knowledge or confidence level. Members who
choose to perform self-care not only obtain treatment immediately, they also avoid the cost and
inconvenience of a visit to a provider. In actual emergencies, the triage staff can calm callers and
help them take appropriate actions until they can access care from a provider.
Providers may appreciate the fact that telephone triage services address members' health concerns
immediately and help them determine the appropriate level of care. Triage services also save
providers after-hours time that would otherwise be spent taking calls from members who are
uncertain about a medical problem.
Telephone triage programs may be quite effective in reducing unnecessary utilization of medical
resources, especially costly emergency services.3 However, a health plan must structure its
telephone triage program so that quality and continuity of care and member satisfaction are not
compromised for the sake of more appropriate utilization.
Shared Decision Making
Consumers' access to healthcare information has increased markedly over the past two decades.
As a result, consumers have become more knowledgeable about medical issues and more

interested in participating in decisions about their own care than in the past. To accommodate
members' wishes to be involved in healthcare decisions, many health plans offer programs that
facilitate shared decision making. In a shared decision-making program, a provider and a
member discuss care options and the provider's recommendations, but the ultimate decision about
care is up to the member. By educating members about their care options and encouraging them
to participate in decisions when possible, health plans hope to improve members' satisfaction with
clinical outcomes and with the health plan as a whole.
Shared decision making is not applicable to all medical situations. For many illnesses and
injuries, one approach to care is clearly superior in terms of safety and effectiveness. A shared
decision-making approach is appropriate when there are multiple approaches that are generally
accepted as valid by the medical community and none of the approaches is best for every
situation. For example, in many cases of breast cancer, lumpectomy and mastectomy are both
viable options and the choice of the surgical approach depends on the member's preferences.
Other conditions that may be appropriate for shared decision making include low back pain,
benign prostatic hypertrophy, prostate cancer, infertility, and menopausal and post-menopausal
symptoms.
When informed about their options and given the opportunity to weigh the risks and benefits,
many members select a relatively conservative approach to care. For example, they may elect to
wait and see how their symptoms change rather than undergoing a diagnostic test immediately, or
opt for a medical treatment rather than surgery. In many instances, the interventions that members
choose are less costly for the health plan than are the other care options that providers might have
recommended.
Health plans should exercise caution with shared decision-making programs to support the quality
of care and avoid the perception that they are simply trying to steer members toward less
expensive approaches to care. A shared decision-making program must present a full range of
treatment options (including no treatment) and the likely outcomes associated with those
treatments in an unbiased manner.
NCQA, URAC, and JCAHO all have standards in support of members' rights to participate in
healthcare decisions. 4
JCAHO standards outline a variety of elements that should be explained to members, such as the
right to be involved in all aspects of care including decisions about life-sustaining treatments or
participation in clinical trials or investigational studies.5
Approaches to Education for Shared Decision Making
By checking HRA results, claims, and encounter reports, a health plan can identify members
whose conditions and associated care options are suited to shared decision making. In order to
participate in healthcare decisions, members need complete, current information about their
conditions, their options for diagnosis and treatment, and the likely outcomes of the different
approaches. Education for shared decision making may come in one or more of the following
forms:
Printed material
Personal or group counseling from providers or other healthcare educators
Support groups, either local or on the Internet

Videotapes
Audiotapes or phone-accessible audio recordings
Internet websites
Interactive computer programs

Videotapes and interactive computer programs are particularly useful for explaining how a test or
treatment is performed. The approach to education for shared decision making should always
include access to healthcare personnel who can answer questions and address specific concerns.
Some programs for shared decision-making education include an assessment of a member's
knowledge to ensure that the member has a good understanding of the relevant issues.
Verification of member knowledge about care options also protects providers and health plans
against charges of malpractice.
When deciding which specific shared decision-making programs to offer, a health plan may
examine claims and encounter reports and then focus its resources on diagnostic and therapeutic
procedures that appear to be overused, based on current CPGs. For example, suppose that the
frequency of surgery for low back pain is significantly higher than national or regional rates for
that procedure and diagnosis. The reason may be that members are not aware of other treatment
options and the possible advantages of the other options over surgery. Information about many
conditions and care options is already available from providers, medical professional
associations, and community agencies such as the American Cancer Society. Before developing
new programs for education about care options, health plans should evaluate existing resources
and use its own resources to meet needs that are not already addressed.
Another way that a health plan can help a member understand care options is to provide a
checklist of questions as a guide for talking to providers or conducting other research. Figure 4B2 lists questions to help a member understand and choose among different treatment options.

Member Participation
The approach to education for shared decision making should reflect the same considerations that
we presented for health promotion programs. Readiness to participate in care decisions is a
critical issue. Although many members welcome the opportunity for more control over their own
health, others are extremely uncomfortable about making healthcare decisions and prefer to
follow provider recommendations. Members may become frightened or angry if pushed beyond
their level of confidence about healthcare, so health plans must be careful to let members
determine how involved they want to be in care decisions.
Provider Cooperation
Many providers are accustomed to making decisions about healthcare with limited input from
members, so they may be unfamiliar with or even resistant to the shared decision-making process.
By showing evidence that many members want more control over their own health and involving
providers in the development of shared decision-making programs, the health plan can encourage
provider cooperation.
Evaluation of Preventive Care, Self-Care, and Decision Support Programs
The evaluation of a preventive care, self-care, or decision support program is a complex process
that considers many different variables. One important basis for program evaluation is progress
toward specific goals. For each type of program, health plans typically identify areas for
improvement and establish goals that reflect the nature of the proposed improvement, the amount
of change projected, and the timeframe for the change. Program goals often specify a subset of
the member population. For example, a health plan's goals for a 12-month period might include
the following objectives:
10 percent increase in the proportion of members over the age of 65 who have received

influenza vaccinations

8 percent increase in participation in fitness programs by members who are at least 20

percent overweight
10 percent decrease in inappropriate utilization of emergency services
7 percent increase in the proportion of women over the age of 50 who receive a

mammogram
However, progress toward goals is not a sufficient basis for determining the overall worth of a
program. Health plans also consider other effects of the program such as changes in

Clinical outcomes
Member and purchaser satisfaction
Results on accreditation evaluations, HEDIS scores, and report card ratings
Relationships with providers
Appropriate and inappropriate utilization
Financial outcomes (i.e., the cost of the program compared to cost savings from the
program)

Ideally, these types of programs will improve clinical outcomes, member and purchaser
satisfaction, quality ratings from external bodies, and relationships with providers. Providers
often play a critical role in the success of a health plan's preventive care, self-care, and decision

support programs. A provider's recommendation that a member participate in one of these

programs greatly increases the likelihood that the member will actually do so. Additionally, input
from providers helps to maintain the scientific soundness, timeliness, and suitability of these
programs' educational materials, CPGs, clinical decision support tools, and self-care information.
On the other hand, a health plan must avoid the perception that it is infringing on providers'
autonomy or interfering in their relationships with members. For example, if a telephone triage
program refers a member directly to a specialist without informing the member's PCP in a timely
manner, the PCP may feel that the health plan is interfering with the care of that member.
While these programs should decrease the incidence of members' seeking inappropriate levels of
care, the health plan should not be surprised at increases in utilization of lower-intensity services,
such as more members receiving immunizations and screening or members making appointments
to see a PCP rather than seeking care in the emergency department.
When considering the costs and benefits associated with preventive care, self-care, and decision
support programs, the health plan must take into account both current and future costs and
benefits. In many instances, health plans have difficulty relating cost savings and health benefits
to a particular program, especially if the health plan has all three types of programs for a
particular medical condition. Another obstacle to demonstrating medical effectiveness and costeffectiveness is that, for many of these programs, the results may not be apparent for at least a
year and often longer. In addition, other factors may influence the results of an initiative. For
example, a local hospital's program to encourage women to obtain mammograms may inflate the
results reported by a health plan's mammogram awareness program.
Role of Information Management in Program Evaluation
Effective information management is necessary for a health plan to measure the benefits and costs
of a preventive care, self-care, or decision support program. A health plan's information systems
must be able to accurately collect, analyze, and report data on

The costs of providing the program to the health plan's members

Clinical research evidence supporting widespread implementation of the intervention
The level of member participation in the program
Changes in the utilization of other services because of the program
Short-term and long-term cost savings that result from the program
Clinical outcomes and member satisfaction ratings for the program
Provider satisfaction ratings
Quality management initiatives and periodic measurements for the program

In addition, the information system must link the different measures in order for the health plan to
determine the overall value of a program. For example, does increased participation in a self-care
program decrease inappropriate utilization of providers' services? How much money is saved for
each dollar invested in an immunization program? Do cost savings come at the expense of
clinical outcomes or member satisfaction?
Additional Strategies for Preventive Care, Self-Care, and Decision Support Programs
The final section of this lesson provides more detail on two of the strategic approaches that health
plans may use when developing and implementing preventive care, self-care, and decision

support programs. These strategies are (1) integration of the programs and (2) partnerships with
other entities.
Integration of Programs
While some health plans have separate programs for preventive care, self-care, and decision
support, other health plans have coordinated and integrated their initiatives for a particular health
issue to create a care continuum that encompasses a wide variety of activities. Such a continuum
may also be linked to a health plan's disease management programs. In many cases, the
development and delivery of integrated programs are driven by member needs identified through
HRA. An integrated approach may be targeted to a specific medical condition, such as CAD, or
to a broader concern, such as health issues for a particular demographic group. Insight 4B-2
provides an example of an integrated program of prevention, self-care, and decision support
activities for peri-menopausal and menopausal women.

Partnerships with Other Entities

Health plans should also explore the possibility of partnering with other entities that have a stake
in health plan member health, such as employers, hospitals and other providers, state and local
health departments, health-oriented community service organizations, and other health plans, for
preventive care, self-care, and decision support programs. Insight 4B-3 describes a cooperative
effort for prevention between a health plan and the American Lung Association. Other less
obvious choices for partners are businesses that provide goods or services that may contribute to
healthy lifestyles (e.g., food manufacturers, restaurants, fitness centers), media that are interested
in public service opportunities, and churches whose members have unmet health-related needs.
Such partnerships often result in more effective programs with a greater level of participation
than a health plan could achieve on its own. Partnering also allows a health plan to share the
financial costs of a program.

Suppose that a health plan decides to partner with an employer on a fitness program. The health
plan and the employer can pool their knowledge to select the type of program and the manner of
presentation that will best address unmet employee health needs. The health plan typically
develops the program according to the risks and other characteristics of the employees, and the
employer can post notices and distribute reminders about the program. In some instances, the
employer may provide a convenient location for the fitness activities, encourage employee
participation through incentives, or subsidize the cost of the program. Increased participation in
the program may improve the overall health of the employees, and healthy employees are more
productive and miss less time away from work due to illness than employees who are less
healthy. Employer sponsorship of preventive care programs also conveys the message that the
employer cares about the well-being of its employees.
Provider partners can be invaluable for the development and implementation of preventive care,
self-care, and decision support programs. As hands-on caregivers, providers may be in the best
position to know the healthcare needs of individual members and the population as a whole.
Further, providers often have the opportunity to address preventive issues when a member visits
for another reason. For example, when a teenager comes in for a pre-camp or pre-sports physical,
a PCP can conduct an HRA that looks at issues such as sexual activity, drug and alcohol use, seat
belt use, and depression.7

Hospitals are likely partners for these programs because many of them already have experience
with preventive care, self-care, and decision support. Hospitals have traditionally been involved
in primary and secondary prevention programs, and some hospitals manage their own telephone
triage services or conduct self-care classes such as first aid.8
In addition, members are often receptive to hospital-sponsored programs because they typically
know and respect the hospitals in their communities.
A health plan may also decide to share its preventive care, self-care, or decision support
experience with other health plans for the benefit of an entire population. Programs such as the
America's Health Insurance Plans (AHIP) Innovations in Health Plans identify and publicize
health plans' best practices for medical management. In some locations, health plans are
collaborating on preventive care programs to (1) help providers and members understand and
remember prevention guidelines and (2) improve the health of the community for the benefit of
all health plans.
Conclusion
By enhancing the care that health plan members give to themselves, health plans can improve the
overall quality of care their plan members receive and decrease unnecessary utilization of care
from healthcare professionals. Self-care and decision support programs can also improve member
and provider satisfaction. Fewer visits to providers mean more time and money saved by
members and more control over their own healthcare. Providers are generally supportive of selfcare programs as well. Improved patient education not only contributes to better health outcomes,
it also leads to fewer visits for minor problems. Providers can focus on more serious health
problems and improve the quality of care they deliver to their patients.
Endnotes
1. Craig S. Russell, "Targeting Approaches Affect Health Care Consumer Behavior and
Cost Savings," Managing Employee Health Benefits (Winter 1999): 54-55.
2. American Accreditation HealthCare Commission/URAC (URAC), Health Call Center
Standards (Washington, DC: American Accreditation HealthCare Commission/URAC,
1999).
3. Robert Mayo, "Education Can Increase Loyalty and Decrease Costs," Managed
Healthcare (August 1999): 28.
4. National Committee for Quality Assurance (NCQA), Accreditation '99 (Washington, DC:
National Committee for Quality Assurance, 1998), 85.
5. American Accreditation HealthCare Commission/URAC (URAC), Health Network and
Utilization Management Accreditation Standards Interpretive Guide, (Washington, DC:
American Accreditation HealthCare Commission/URAC, 1998), 72.
6. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 1998-2000
Standards for Health Care Networks (Oakbrook Terrace, IL: Joint Commission on
Accreditation of Healthcare Organizations, 1998), 72-73, 76-77, 94-95.

7. "Best Practices in Women's Health: Hormone Replacement and Mid-Life Issues,"

Healthplan (May/June 1999): 56-60.
8. Ibid., 336.