Promoting Excellence : New End-of-Life Benefits Models in Blue Cross & Blue Shield Plans : Anthem Blue Cross Blue Shield of New Hampshire

Anthem Blue Cross Blue Shield of New Hampshire
3000 Goffs Falls Road
Manchester, NH 03111-0001

Advanced Care for Advanced Disease

Joyce Keslo, RN, BSN, CCM
Program Leader
(603) 695-7078
[email protected]

"Before this program was in effect, patient bounced back and forth between the hospital and home, and care became fragmented. Now,families feel more confident in their role as care- givers in the home because of the amount of support they receive." - Joyce Keslo, RN, BSN, CCM

Program Goals and Objectives
To improve the quality of end-of-life care by:

Program Description
Advanced Care for Advanced Disease provides for hospice care in the home. Care is delivered by nurses from the Visiting Nurse Association & Hospice Division. The internal structure of the program allows for three levels of care, defined and monitored for quality of care by case managers, who work closely with the hospice nurses.

The levels of care include:

Patients might be moved in and out of different levels of care, depending on their needs. This internal design is meant to put flexibility in the plan. Services that are provided are not strictly defined, so that an unmet need (for instance, a blood transfusion), could easily be worked into the plan of care.

Advanced Care for Advanced Disease is an enhancement of Anthem Blue Cross and Blue Shield (Anthem) of New Hampshire’s Case Management function. This program was added to allow members access to hospice care without having to restructure the benefits. The Case Management program allows the case managers autonomy and flexibility in their delivery of service and decision-making options.

All commercial members of Anthem BCBSNH are eligible for this program. New cases have been incorporated into the pre-existing caseloads of the case managers. To date, no new staff has been required, although an additional case manager joined the team in July 2001, which will allow an existing case manager to devote more time to program management.

Historical Perspective
To the company’s credit, this program began as a response to member dissatisfaction. Anthem had received complaints regarding the quality of care being delivered by particular hospice providers. Reports showed consumer dissatisfaction with the hospice staff ’s knowledge of pain management. When Anthem received comments that service was unsatisfactory, they initiated a quality improvement process. The decision was made to develop a hospice program that would include end-of-life and palliative care.

The initial team consisted of an interdepartmental group whose membership included contracting agents, network managers, provider representatives, a medical director, case managers, a social worker, clinical quality and disease management. All of these participants brought passion to their mission. A partnership with the Visiting Nurse Association and Hospice providers was developed and enthusiastically received. The Clinical Quality Department, in collaboration with Visiting Nurse Association & Home Health and Hospice, created standards of clinical practice for care. Annually, a Hospice Advisory Board reviews the program and makes recommendations to improve and enhance it. Joyce Keslo, RN, BSN, CCM notes that one of the benefits to having the visiting nurses provide care is that this encourages a smooth transition from home care to hospice at the point when that service becomes necessary. She says patients become familiar with the caregivers and with the hospice philosophy while receiving care for their advanced disease. By the time they need hospice, they are more comfortable with the idea.

One obstacle with the program that Anthem is trying to address, however, is that of physician buy-in. The medical community at large, as well as the general public, requires more education about the benefits of Advanced Care for Advanced Disease (ACAD). Keslo noted that internally at the Plan, many people don’t know what hospice is, or what it involves. The education of the community would advance the principal of ACAD. Currently the team is working with various stakeholders in the community to achieve this goal.

Historically, case managers haven’t had the ability to show what is called “Hard Savings. They will now be comparing the per diem rate for home care with the per diem rate for acute care, to determine if the program is cost effective. There is always the concern of “adverse selection” in this kind of care, so the data is being analyzed. Measuring quality impact of the program is equally as important—the fact being, that this program is the right thing to do for both customers and the community. Medicare data shows that 58 percent of health care costs are incurred in the last six months of life. Jean Montana, RN, BSN is confident that the program will show its worth in every way.

It would be ideal if the medical community were aware of end-of-life issues and options available for provision of services. More education and acceptance is needed for the entire population, but due to the nature of discussions of death and dying, this is often not a priority. At this time, there is no formal community or provider education component to this program. There is however the potential of partnering with the EPEC trainers to educate New Hampshire providers.


Publicity efforts have been modest. There has been some effort to publicize the program within the network. A mailing to providers that announced the PBS ® series with Bill Moyers was sent (in conjunction with the hospice program information) prior to televising the program. Employees associated with ACAD discussed with providers and local community groups the benefits and availability of the program. As new certificates of coverage are written, information about the ACAD program will be added.

Since this service has been placed in the Case Management Division of Anthem, it has not required additional staffing.

The company has agreed to the expansion of the program as part of their corporate initiative to improve the health of members. Quality end-of-life care is beneficial to everyone involved. They are moving forward to the next stages of delivery of service. A Palliative Care Model, which will add a fourth level of care to the program, is in development. Plans are being considered to extend service beyond the six months hospice benefit that is now offered. The company is also working with physicians to develop an extended list of diseases to consider for inclusion in the program. They are looking at the feasibility of adding a per diem rate with the Visiting Nurse Association if a member has to go to a skilled nursing facility, hospital, or inpatient hospice. Providing coverage is seen as the right thing to do, and it looks as though the quality and cost-benefit outcomes are positive, then these become compelling reasons to continue with the program. Montana states it is an extension of the caring that Anthem has always shown in recognizing and supporting community endeavors. It also supports the Anthem Mission to improve the health of its members.

Key Elements of Success

Measures of Program Success
The data that has been collected has been satisfaction data. Questionnaires have been given to the primary caregivers, which ask, among other things, if providers of care are knowledgeable, and if pain management has been satisfactory. Feedback received from customers, although informal, has shown tremendous satisfaction with the program.

Information on provider satisfaction, although mainly anecdotal, shows that physicians are pleased with the program. The feedback received by the Clinical Quality Improvement Committee has shown an excellent response from providers, and the Hospice Association reports great interest in the program.

Measures of success include:

Necessary Steps
Jean Montana notes that caseloads must be monitored to ensure that the case managers are coordinating care. She is looking forward to the addition of the fourth level of care, as the need for it has been consistently demonstrated.

As for other issues that need to be addressed, the ever-present discomfort that people demonstrate around end-of-life issues and issues of death and dying, hinders this program from being even more effective. Education of providers, patients and the public will help transform the culture of fear surrounding these issues.

What I Wish I ’d Known ...
If Montana had it to do over again, she would include a Program Manager in the design from the beginning. She feels that if the company had initially been able to devote more specific resources to development of the program, they would already have the Palliative Program in place, and would be able to track outcome data more confidently.

This descriptive summary is based on an interview conducted by Susan Butler with Jean Montana and Joyce Keslo, June 14, 2001.

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

Promoting Excellence