The four case study organizations all had special programs for seniors generally, to help seniors maintain their health and avoid the need for medical care. They included patient education and medication review programs. There were also programs to promote better mental health either through formal treatment or through having volunteers call potentially isolated seniors to give them someone with whom to talk. This section summarizes a few examples of the programs we saw during our site visits.
Health Education and Disease Prevention.Keystone East and Kaiser Colorado had health education and prevention programs, mostly for elderly members who did not have significant illness. At Keystone East, enrollees classified as being at moderate or high risk for adverse health outcomes were given the brochure “Eating Right” to promote healthful nutrition. Keystone East also had the following programs oriented toward Medicare members:
Each quarter, enrollees receive an attractive, multicolored magazine devoted to wellness topics for seniors as well as to plan procedures. For example, the September 1997 issue included information on nutrition, mental alertness, exercises to enhance flexibility, calcium intake, periodic screening, sleeplessness, and hypothermia. It also contained information on selecting a primary care physician, when to access the emergency room, financial/retirement planning, the plan’s goal that physicians see patients within 30 minutes of the appointment time, and the availability of discount golf passes.
Around their birth dates, women enrollees are sent reminders to obtain mammography screens.
The A to ZZZZZs: Easy Steps to Help You Sleep, a booklet designed to promote good sleeping habits, is offered at no charge to enrollees, along with an audio cassette tape that contains sleep information and muscle relaxation exercises.
Both Keystone East and Kaiser Colorado conducted campaigns to promote influenza and pneumococcal inoculation. Keystone East sends out annual mailings to Medicare members to encourage receipt of influenza inoculation. In the winter prior to our visit, 80 percent of Kaiser Colorado senior members received flu shots through the health plan; some unknown proportion of the others may have received vaccinations in community settings. To achieve such a high rate, the plan mailed postcards to members and held flu shot clinics. In addition, volunteers telephoned members who had joined the health plan recently to encourage them to be inoculated. Plan records also indicate that at least two-thirds of seniors have had pneumococcal inoculations.
Kaiser Colorado employs six health educators. Only recently, however, has there been a focus on the senior population. Meetings for members who are caregivers, called “When Your Parents Need You,” were initiated in March 1997. Between 30 and 40 members attend each session. More recently, classes entitled “Care for Caregivers,” “Wellness as We Age,” and “Yoga for the Great Years” have been held. Members who attend pay nothing or a small fee, depending on whether they have enrolled in the basic or the high option. More recently, intergenerational sessions have been held that deal with stress management, heart problems, arthritis (in conjunction with the local chapter of the Arthritis Foundation), and diabetes. Some of the classes are open to nonmembers.
Pharmacy.Many health plans serving the elderly have “tote bag” or “brown bag” programs that entail members’ collecting all their medications, prescription and nonprescription, and having them reviewed by a health professional. Keystone East encourages new Medicare members to review all their medications with their primary care physicians.
Kaiser Colorado has undertaken several pharmacy-related initiatives, some of which are discussed in the “Disease Management” section. In addition, several of its clinics have doctorate-level pharmacists, and there are approximately 15 such people throughout the Kaiser Colorado system. Most of these 15 pharmacists are board certified in pharmacotherapy,18 and some have specialized training in oncology and infectious diseases. The plan is rapidly adopting mechanisms to allow professionals at both BS and PharmD levels greater opportunities to deliver clinical services directly.
The clinical pharmacy service of Kaiser Colorado has focused on a number of areas that are relevant to the frail elderly, including the prescription of benzodiazepines, which are sedative-hypnotic medications that have been associated with falls and hip fractures. The pharmacy service screens enrollees for whom these medications have been prescribed and encourages physicians to consider alternatives or shorter-acting benzodiazepines (for example, Lorazepam). Also, the formulary has been restricted for some of these drugs that pose the greatest risks of side effects (such as Dalmane) to minimize their use. Finally, the service has also sought to identify seniors with the diagnosis of depression, to ensure that the appropriate antidepressant has been prescribed.
Behavioral Health.All of the case-study organizations allow enrollees to self-refer for behavioral health services. HMO Oregon and Keystone East, as for many other health plans, “carve out” behavioral health services and contract with a managed behavioral health organization on a capitated basis. Kaiser Colorado has a separate mental health service, which is treated like any other specialty department. Also, at Kaiser Colorado, a pilot project was initiated in September 1996 that entails placing a psychologist at one of the larger primary care clinics, both to see patients and to consult with physicians. One reason for the on-site presence is to overcome resistance of some patients receiving mental health services. None of the plans visited has made a special effort in geropsychiatry.
Volunteers. Some plans have volunteer programs. Kaiser Colorado, at one of its 14 clinics in the Denver-Boulder area, has initiated a friendly telephoning program on a pilot basis known as “Caring Callers.” Three volunteers--all of whom are more than 70 years old and one of whom is over 80--meet at the clinic every Monday morning and, between them, call a panel of some 20 members who are chronically ill and socially isolated. Many of these members have been identified as depressed or lonely, through the assessment process described above. Each call takes between 20 and 30 minutes. A “Caring Caller” volunteer training manual has been prepared, which includes information on protocols and guidelines for making calls, as well as phone tips and a script for answering some frequently asked questions. Volunteers receive a half-day of training. The program may be expanded to other clinics.