Nurse-led Health Case Management

By Innomar Strategies

The Benefits to Group Plan Members and Sponsors
The continued growth of new high-cost specialty medications for the treatment of complex chronic diseases has challenged insurers to balance group plan members’ needs for effective treatment of their chronic diseases with long-term benefit plan sustainability, and the cost management needs of plan sponsors. Great-West Life has met this challenge, which it terms a dual bottom line, by offering plan sponsors a nurse-led Health Case Management program designed to monitor and manage plan member treatment plans while helping to achieve better and more cost-effective health outcomes.

In 2012, Great-West Life engaged HealthForward Inc. and its qualified nurse health case managers to design and provide comprehensive case management support and assistance to plan members and their covered dependants with chronic conditions, such as rheumatoid arthritis, Crohn’s disease, psoriasis and severe asthma. After 5 years, this Health Case Management program remains one of the most accepted and valued Great-West Life services provided, and its value has been demonstrated in a recent Canadian health outcome study.

Here is an overview of nurse-led Health Case Management and the benefits provided:

What is nurse-led Health Case Management?

Nurse-led Health Case Management provides a single point of contact to each plan member to ensure they are taking the right drug; are adhering to their prescribed treatment regimen; fully understanding their treatment plan and the expected results; and have access to support, education, and the assistance they need.

A HealthForward HCM is assigned to work with each plan member and becomes an advocate and interface between the plan member and individuals in their circle of care, including their physician, Great-West Life, family, pharmacy, and a manufacturer-sponsored patient support program (PSP).

Based on a series of touch points over a trial period, the nurse HCM will assess the treatment plan effectiveness and adherence to treatment. Additionally, through a collaborative process with the individual’s circle of care, the nurse HCM will also assess outstanding healthcare needs and health literacy, and devise a personalized plan to provide education and access to support services as required. They will also aid the plan member in understanding any benefits or programs available to them under their benefit plan.

If the plan member is not benefitting from the medication at any time during the trial period, the nurse HCM will work in collaboration with Great-West Life to understand treatment options available with a goal to potentially change medication. Due to the close collaboration between the nurse HCM, physician and Great-West Life, this process can often be expedited to ensure that there are minimal gaps in treatment.

How do plan members benefit from nurse-led HCM?

Plan members with chronic diseases benefit from a nurse HCM single point of contact that will champion the comprehensive support and access to effective treatment required to achieve better health outcomes at an often confusing time in their treatment journey:

Regular monitoring and collaboration between nurse HCMs, physicians, and Great-West Life ensures that plan members have access to the right medication as quickly as possible. If drug switching or dosage changes are required, the nurse HCM will help to facilitate this process at any time during the monitoring period.

Plan members also benefit from the continuity of a single nurse HCM. They develop trusting relationships during the Health Case Management process, and receive emotional support.

Adherence to prescribed treatment plans, including taking medication as directed, is linked to improved health outcomes. More frequent monitoring by the nurse HCM helps patients understand the importance of adherence, and provides the opportunity to motivate the individual to take the drug as prescribed.

Finally, ongoing touchpoints allow plan members to receive customized education, gain clarity of understanding of their treatment and benefits, and learn about community resources when they are needed.

Why should insurers consider HCM for their plan sponsors?

Plan sponsors offer group benefits to support their employees so they can work on productively, they extend benefits to employee spouses and dependants, and they rely on insurers to manage their benefit costs as effectively as possible. Health Case Management affords plan sponsors the assurance that their plan members are on the right medication, and will benefit from the treatment provided, without incurring unnecessary costs. The ability to collect objective health-outcomes data through a Health Case Management program also enables ongoing program evaluation and decision-making.

Health Case Management also translates into workplace benefits. A recent health economic outcome research study of Canadian patients performed by HealthForward and Great-West Life demonstrated that, compared to routine care alone, Health Case Management improved quality of life and health outcomes in rheumatoid arthritis and psoriatic arthritis patients treated with biologics: 84% of patients experienced improved quality of life scores versus 62% on routine care alone; 54% experienced lower disease activity versus 28% on routine care alone; and 46% of patients experienced remission of their disease versus 13% of patients on routine care alone.1 These significant improvements in quality of life, disease activity, and especially disease remission, directly relate to potential workplace benefits, including:

  • decreased work disability
  • increased work productivity
  • reduced absenteeism
  • reduced presenteeism

In an area of cost growth, such as the use of high-cost biologics for the treatment of chronic diseases, Health Case Management has proved to be one of the most important tools for Great-West Life to effectively and responsibly manage costs on behalf of plan sponsors. With 5 years of experience, the evidence has validated the vision: nurse-led Health Case Management has ensured that plan members have access to the right medication as quickly as possible, resulting in improved quality of life, health outcomes, and a positive impact on the workplace.


Yap B et al. Improved Health Outcomes in Patients Receiving Health Case Management (HCM). Poster presented at CADTH Symposium 2017; Ottawa, ON; 23-25 April 2017. Accessed here.