April 2025

It’s important for individuals to prepare advance directives in order to help maintain autonomy during periods of incapacity or at the end of life. 

April 16 of each year marks National Healthcare Decisions Day (NHDD) as a way to encourage people to share their wishes for care through the end of life, and serve as a reminder of the importance of advance care planning.

It’s not easy for one to think about the inevitability of life’s progression to its end, especially when one is facing a serious or terminal illness.  But making decisions about advance care planning and having uncomfortable but necessary conversations with loved ones regarding end-of-life wishes can be invaluable to families when a health crisis strikes.

For some physicians and providers, the intersection of their medical training – to heal their patients – with the knowledge of how a disease progresses, the conversation about end-of-life isn’t easy for them, either. 

It’s important for individuals – your patients – to prepare advance directives in an effort to maintain autonomy during periods of incapacity or at the end of life. It’s understood that there are barriers to broaching the subject about completing an advance directive, such as lack of time during the appointment with a patient and discomfort with the topic.

For the patient, lack of knowledge, fear of burdening family, and a desire to have the physician initiate the discussion are common barriers.

To overcome these barriers, physicians and providers are encouraged to begin communication at multiple visits, including allowing the patient the opportunity to ask questions. Involving the family or a proxy early and over time can help the process.

It may be helpful to begin to integrate advance directive discussions at selected stages of the patient's life, such as when a new diagnosis has been made or as health status changes.

Two important components of advance care planning include:

• a living will, which can include written instructions for end-of-life care, and,
• a health care proxy, which allows individuals to appoint a health care agent – someone they trust to make health care decisions for them – if they are incapacitated or unable to do so themselves.

For more information and guidance, please visit:

• Implementing Advance Directives in Office Practice by the American Academy of Family Physicians
• The Conversation Project by the Institute for Healthcare Improvement.

Experts agree no matter the age, people should consider taking the time to have these conversations, designate a health care proxy, and create a living will. It may very well prevent agonizingly difficult decisions down the road.
 

Integrating screenings into practice, even if patients are asymptomatic, can lead to better health outcomes and reduced transmission rates.

Throughout the year, the Quality Management and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

Osteoporosis Management in Woman Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case Manager will outreach telephonically to Medicare members that fall into the Osteoporosis Management in Woman Who Had a Fracture (OMW) measure.

• Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.

Independent Health’s Case Manager will contact members to discuss their fracture, provide education on fractures and falls prevention, and discuss options for gap closure.

The Case Manager will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case Manager will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.

The Case Manager will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.

• Timeframe: This outreach is on-going. Monthly, new members who fall into this measure are called. 

Eye Exam for Patients with Diabetes (EED) Member Outreach 
Independent Health will be facilitating outreach telephonically to Medicare members that have a gap in care for the Eye Exam for Patients with Diabetes (EED) measure.  

• Target population: Medicare HMO members with a diagnosis of Diabetes (type 1 or 2) who have not had a retinal eye exam. An eye exam in the year prior must be negative for any type of retinopathy. If year prior eye exam is positive, then an eye exam in the current measurement year is needed.

• Outreach method: Outbound telephone call campaign.

Independent Health will call members and discuss the option of an in-home eye exam with Stall Senior Medical (SSM). If the member is interested, Independent Health will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the members’ Primary Care Physician (PCP) for follow-up.

• Timeframe: Campaign to kick off in mid-to-late March and run through December 2025

Gaps in Care Reminder Calls 
Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a vaccination to complete the gaps in care.

• Target populations:

Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.

Medicaid Managed Care and Child Health Plus members (ages 9-12) who have started but not completed the series for HPV vaccinations

• Timeframe: Call campaign is scheduled to begin in April 2025

Falls Prevention Campaign
This campaign targets Medicare members identified as having a high likelihood of falling or history of falls to provide fall prevention education and encourage members to speak to their doctor about ways to prevent falls.

• Target population: Medicare members who have a high likelihood of falling or a history of falls.
• Outreach method: Outbound telephone call and email campaign.
• Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.

Physical Activity Campaign
This campaign targets Medicare members identified as having low physical activity levels to provide education regarding the benefits of physical activity and encourages members to speak to their doctor about ways to be more active.

• Target population: Medicare members who have low physical activity levels.
• Outreach method: Outbound telephone call and email campaign.
• Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.

Bladder Control Campaign
This campaign targets Medicare members identified as having urinary incontinence and encourages them to speak to their PCP regarding urinary incontinence and potential solutions.

• Target population: Medicare members who self-identify as having urinary incontinence.
• Outreach method: Outbound telephone call and email campaign.
• Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.

Physical and Mental Health Campaign
This campaign targets Medicare members identified as having concerns with their physical or mental health to provide education regarding who to contact about any physical and mental health concerns and encourages them to speak to their doctor about these concerns.

• Target population: Medicare members who are identified as having concerns with their physical or mental health.
• Outreach method: Outbound telephone call and email campaign.
• Launch Date: Telephonic outreach will begin in late April; Email campaign will occur between May through July.

 

View our up-to-date formularies and policies online.

Knowing what health plan members want improves engagement and connectivity - Healthy Vision blog, March 20, 2025