BCBS Michigan Case Study

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

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
Q1
Pre
HCPA
Q2
HCPA
Q3
HCPA
Q4
Post
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 & Certification
Build 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
Curriculum
1. CCP Core
Curriculum
• Test knowledge via
standardized,
validated exam
(required for national
certification)
2. CCP Exam &
Certification
2. CCP Exam &
Certification • Access CCP member
monthly webinars/
archives and tools;
MI video skill‐
building library
3. Ongoing
Skill‐Building
3. 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 Training
Develop 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, verbal
patients 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 not
using 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 not
using 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 Sessions
Support 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 Q2
61% 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 Q2
2.6 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
Change
Eliciting reasons for change
from patient vs. telling them
why they should change
Q1 Q2
2.3 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

Please Submit Questions for Discussion
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Obtain Your Certificate of Completion
• Today’s event is preapproved for 1.0 hour toward CCP
recertification and may meet other professional certification
or licensure CE requirements.
• All registered attendees may obtain a CE certificate now by
completing an evaluation form at:
http://healthsciences.org/ce_program_evaluation.php
• Registered attendees will receive a follow‐up email with a
link to the evaluation form shortly.
• 2010/2011 LC replays and PDFs provided at no cost through
the online CCP program or via individual/group subscription.

Upcoming Learning Collaborative Events
Date Topic Presenter
Sept 9
Transitional 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
Oct 7
Diabetes
Update
Maria Collazo‐Clavell, MD, Endocrinologist,
Division of Endocrinology, Diabetes, Metabolism
& Nutrition, Mayo Clinic
Nov 4 TBA
Dec 5 Break
Learn more or register now at: www.HealthSciences.org

Learning Collaborative
Community 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

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