Section 2: Engaging Stakeholders in a Care Management Program

Stakeholder support, beginning with program design and continuing through the evaluation, is critical to a successful Medicaid care management program. Stakeholders should be involved during each stage of the program to build support for it, provide suggestions for its design, and participate in evaluation and continuous quality improvement activities. Stakeholders include senior Medicaid and agency leadership, the Governor's office, the provider community, the patient and advocacy community, the State legislature, and the Centers for Medicare & Medicaid Services (CMS).

Incorporating information from the 13 State Medicaid care management programs in the initial AHRQ Learning Network and additional literature, this section of the Guide, Engaging Stakeholders in a Care Management Program, provides information to State Medicaid staff and policymakers about the:

• Importance of engaging key stakeholders.
• Strategies for developing relationships with key stakeholder groups.
• Communication strategies for demonstrating program value.

Importance of Engaging Key Stakeholders

Involving stakeholders during all stages of a care management program can lead to early buy-in, successful program design, and establishment of long-term support for the program. The following subsections outline three strategies to engage stakeholders-identifying "champions," establishing relationships and communicating regularly with stakeholders, and managing expectations of the care management program.

Identify Champions

One strategy for stakeholder engagement is to identify program "champions" to assist with program rollout or expansion and to build program sustainability. Program champions are stakeholders actively involved in the care management program and influential among their peers. Influential program champions can include State legislators and their staff, staff members from the Governor's office, senior Medicaid leadership, and providers. Program champions can help program staff plan and design a program, provide expertise based on their experiences, promote program continuation and sustainability, and help manage other stakeholders' expectations. Moreover, program champions can provide feedback on the program by identifying areas for program refinement and offering comments on new initiatives. Program staff can share preliminary evaluation results with champions to better understand how stakeholders might interpret these results.

North Carolina initially identified program champions through meetings with primary care providers and other community Medicaid providers interested in participating in the program. The State also locates champions through its Physician Advisory Group. North Carolina engages its program champions regularly by updating its program Web site and soliciting input on proposed initiatives.

Wyoming is piloting an electronic health record, called the Total Health Record, with providers identified by program staff as champions. The champions provided feedback on the ease of use, billing, and the pay-for-participation program associated with the initiative.

Communicate Regularly

Ongoing communication represents another strategy to secure and maintain stakeholder support. By maintaining regular communication with stakeholders, program staff can establish themselves as the key contact or source for information about the program. Serving as the key contact ensures that stakeholders receive recent and correct program information and provides a resource for stakeholders' questions or concerns. Once the program is implemented, communicating routinely with stakeholders regarding program successes, failures, and new initiatives will help manage expectations and build support for the program.

Washington program staff consistently offered feedback and information to the Governor's office during the first 4 years of their care management program. Subsequently, their input influenced the Governor's initiative on chronic care and impacted care management legislation. The Governor of Washington issued a directive on chronic care improvement aiming to develop a new model of chronic care management that supports the medical home model, supports evidence-based medicine and use of information technology, addresses health disparities, improves coordination of care, and applies the principles of continuous quality improvement.

Manage Expectations

States also have maintained stakeholder support effectively by sharing program outcomes early and often. In sharing program successes and outcomes, program staff should consider what types of outcomes stakeholders will find most meaningful. For example, providers and consumer groups might be interested in standardized measures that allow for comparison across providers; meanwhile, the legislature might be interested in cost savings. Program staff should identify early outcomes that key stakeholders would consider a "success" to demonstrate and communicate results.

North Carolina routinely shares successes with program stakeholders through its Web site, annual reports, and a two-page At-A-Glance document. Program staff regularly update the At-A-Glance, which summarizes the program's approach, clinical improvement initiatives, pilot programs, and performance and results.

Strategies for Developing Relationships with Key Stakeholder Groups

Developing relationships with senior Medicaid and agency leadership, other State agencies, the Governor's office, the provider community, the patient and advocacy community, the State legislature and staff, and CMS is critical for a care management program's success. For each stakeholder group, the following subsections outline strategies for stakeholder engagement during the planning, designing, implementation, and evaluation stages of a care management program.

Senior Leadership

Medicaid and senior agency leadership are unique in their capacity to influence program design, staffing, resources, and budget allocation. Program staff should engage senior agency leadership during all stages of a care management program to understand their goals for the program and ensure support.

Planning and designing stages. Program staff should involve senior leadership during the initial planning stage to take advantage of their expertise, as well as to understand their program goals. Senior leadership, including the Medicaid Director, the Secretary of Health, and the Governor's office might have specific program goals or might have areas and directions that they are uninterested in pursuing. For example, senior leadership might be interested in testing electronic medical records through the care management program. In addition, other senior leadership within the State might want to focus the program on a particular population or chronic condition.

Implementation and evaluation stages. Program staff should communicate regularly about program successes and areas for improvement with senior leadership. Keeping senior leaders apprised of issues or situations as they develop will help manage expectations of the care management program and build leaders' support. One strategy for facilitating regular communication is to E-mail regular program updates to senior leaders detailing program successes, issues, and plans. These updates could also serve as talking points if staff are asked to discuss the care management program.

Arkansas is currently linking birth certificate data and Medicaid claims data to analyze the effectiveness of its Antenatal and Neonatal Guidelines, Education and Learning System program, known as ANGELS, on decreased neonatal intensive care unit admissions and complications. State staff meet regularly with the Medicaid Medical Director to communicate early findings and to receive input.

In designing the evaluation strategy and presenting the results, program staff should work with senior leadership to understand their particular interests and program goals and should tailor specific evaluation reports accordingly. Understanding senior leaders' program goals and subsequently tailoring evaluation results is an effective strategy to build support for the program and manage expectations.

Other State Agencies

Coordination and communication with other State and community programs represents a crucial part of Medicaid care management programs. Medicaid beneficiaries are more likely to have issues related to poverty (e.g., transportation or housing needs) and behavioral health that can be met through established programs.

Planning and designing stages. States should communicate with other State agencies, solicit feedback on program design, and identify any potential synergies between the new care management program and established State programs. For example, synergies might exist between an established Department of Public Health diabetes program and the new care management program targeting diabetes. The two programs can potentially share lessons learned. Opportunities might exist to coordinate more directly with established programs.

Washington partners with other State agencies that also work on chronic care management. The care management program works with the Aging and Disability Services Administration to develop educational materials, apply similar approaches for members, use equivalent measures related to health outcomes, and employ similar approaches for program evaluation.

Implementation and evaluation stages. During the implementation and evaluation stages, program staff should work with other State agencies to coordinate interventions and outreach materials.

Pennsylvania's disease management program coordinates with its State-staffed intensive care management unit, which was established in July 2004, nearly a year before the State contracted with a vendor to provide disease management services. Fifteen nurse care managers in the care management unit work with patients having a wide range of conditions (e.g., hemophilia, burns, spinal cord injury, pain management, organ transplant). The care management unit and vendor meet biweekly for "exception meetings," during which they discuss moving patients between the two programs to best meet their needs.

Provider Community

Providers are critical to any care management program; interested providers will endorse the concepts of the interventions with patients, identify interventions needed for patients, and provide valuable program input. By involving providers, States build long-term support for the care management program in addition to improving program outcomes and physician practice. Providers can offer suggestions for program refinements based on their clinical expertise and experience with the care management program. Finally, provider champions can help secure buy-in for the program from other providers and additional stakeholder groups.

States can solicit and garner support from physician and provider organizations and societies (e.g., Pediatric Society, Public Health, Academy of Family Physicians, and Hospital Association). These organizations can endorse the program to their memberships and affiliations as well as advocate for the care management program to senior leadership, patients, and legislators. Please go to Section 4: Selecting Care Management Interventions for more information on provider interventions.

Wyoming's vendor provides two network coordinators to market the care management program to providers. Specifically, the network coordinators serve as the ongoing provider liaison, educate providers about the program, and conduct educational sessions on evidence-based guidelines. The network coordinators also work with State professional societies, including the Wyoming Hospital Association, the Wyoming Primary Care Association, and the Wyoming Nursing Association, to promote the care management program.

In addition to identifying provider champions as described earlier in this section, States have succeeded in establishing standing advisory committees. Both strategies offer an effective way to involve providers in a State's care management program.

Checklist: Physician Advisory Group √ Include representation from varied specialties. √ Cover different regions of the State. √ Limit the group size. √ Work on a clear set of issues.

Iowa created a clinical advisory committee in a 2-month timeframe in 2006. The standing clinical advisory committee now includes nine members who represent primary care providers throughout the State. Responsibilities of the clinical advisory committee include the following:

• Assess member use of services.
• Assess new therapies and technologies.
• Review Medicaid policies and recommend changes.
• Support member and provider education.
• Promote preventive services to members and providers.

North Carolina's Physician Advisory Group advises the State on its care management program. Since 1997, the Physician Advisory Group has provided input on overall medical policy and Medicaid system reform topics, including the following:

• Development of care and disease management initiatives.
• Pharmacy and therapeutics.
• Medical coverage.
• Cost review and cost containment and effectiveness.

Planning and designing stages. During the planning and designing stages, program staff should involve the provider community to garner input on clinical aspects of the care management program and to develop champions and others to serve as ambassadors to patients for the program.

Washington convened a provider focus group in March 2006 to engage providers to offer input on a new care management program design. Providers were chosen to participate based on their previous participation in chronic disease collaboratives and on their experience with the chronic care model. The State covered several questions in the focus group:

• Does your practice limit the number of Medicaid enrollees?
• What are the challenges of taking care of disabled or chronically ill Medicaid patients?
• What could the State do to support you in taking care of Medicaid patients with chronic illnesses?
• Which services could we provide (e.g., data, nurse call line, care coordination) that would help you?
• Would providers support a system of receiving a bonus for quality improvement?

By involving providers in program planning and design, staff can collect provider feedback and gain provider champions. Early engagement leads to increased ownership and support for the care management program.

Potential Benefits of Provider Engagement Endorse the concepts of the interventions with patients. Encourage members to take advantage of the program. Participate in reporting and data exchange included in the program. Identify interventions needed for patients.

Implementation and evaluation stages. Providers should be involved during the implementation stage to achieve early buy-in to the program. To activate providers during the implementation stage, States have formed provider advisory boards or groups to provide feedback on program interventions, measures, guidelines, and strategies.

Indiana's care management program aims to improve quality in primary care practices. During early implementation for Indiana's initial care management program, the State held a series of four quality improvement collaboratives in which provider practices were invited to participate. The collaboratives focused on diabetes, congestive heart failure, and care for children with asthma. The participating practices set quality improvement goals and reported their performance once a month. Ideas were shared during monthly conference calls and via an E-mail listserv. The nurse care managers and telephone center leads also attended the collaborative learning sessions.

Providers also should be involved during the evaluation stage to provide feedback on preliminary results, offer suggestions on areas for program refinement, and comment on new initiatives within the care management program. Finally, providers can advocate for the care management program to State legislators and their staff and agency leadership.

Kansas' care management program was nearly cancelled because of budget restrictions and a new administration. However, local physicians' support of the program created enough pressure to reverse the decision to cancel the program.

States involve providers during the implementation and evaluation stages through their standing advisory committees or targeted outreach to physician and provider organizations and societies, as discussed above.

Patient and Advocacy Community

A significant component of a care management program focuses directly on understanding the patient and his or her needs and subsequently providing appropriate interventions. By securing the patient and patient advocacy community's support, States have received useful input on program design and significant support for program sustainability.

Advocates and Lobbyists Stakeholder lobbying also can influence the legislature and Medicaid agency. A strong lobby might exist for a particular disease (e.g., end stage renal disease or hemophilia) that is vocal enough to convince the legislature or Medicaid agency to include the disease in the care management program. Communicating routinely with lobbyists regarding program successes, failures, and new initiatives will help manage expectations and build support for the program. A key ally can be won if program staff identify ways to support advocacy group initiatives through the care management program.

Planning and designing stages. By involving consumers during the planning and designing stages, program staff will be better able to gauge the possible impact of certain interventions and will be able to design a better, more effective program overall. Attaining support from the patient and advocacy community provides insight into the patients' needs and fosters support for program sustainability.

Pennsylvania's vendor assembled Regional Advisory Committees (RAC) in which beneficiaries and physicians met regularly to provide feedback on disease management activities and input on the evaluation and selection of potential vendors in the early planning stages. The RACs provide ongoing feedback to the vendor and State.

By establishing infrastructure such as standing committees or focus groups, program staff can plan the care management program and identify areas for program improvement.

Implementation and evaluation stages. Engaging patients during the implementation and evaluation stages of a care management program can also help program staff understand the program's effects on patient behavior and identify areas for program improvement. In addition, engaged patients are more likely to follow providers or care managers' recommendations. Finally, patients can advocate for the care management program to State legislators and senior agency leadership.

Involving the patient community through committees and focus groups can represent an effective strategy to build support, increase awareness of the program, and improve program outcomes.

State Legislature

Similar to senior leadership, the State legislature retains the ability to influence the care management program significantly. Legislators are unique in their capacity to influence program design and budget allocation through the legislative cycle. Program staff should work with State legislators and their staff during all stages of a care management program to understand their goals for the program and ensure support.

Lessons Learned: Communicating with the State Legislature Coordinate and communicate with legislators and their Staff. If legislators understand where the program is going and are involved in its development, they likely will continue supporting it. Share information about other State's programs. Because legislators also might communicate regularly with other States, they might be able to provide access to or insight into other States' programs.

Planning and designing stages. Since legislators might lack the necessary information to realize the impact of certain design features, program staff should coordinate and communicate regularly regarding the care management program. Specifically, program staff should understand the State legislature's expectations of the program, program design requirements, and whether a mandatory savings requirement exists. In addition, since State legislators and their staff will not necessarily approach program staff for input, program staff should remain proactive and set up meetings to exchange ideas. Program staff should become the key contact for questions surrounding the care management program for legislators.

Implementation and evaluation stages. Once the program is implemented, program staff should involve the legislators on an ongoing basis; periodic briefings can help build support and manage expectations in case the program progresses more slowly or has different outcomes than anticipated.

State legislatures often require savings guarantees from care management programs. However, because cost savings might be an unrealistic expectation for the program's first few years, communication with the legislators and senior leadership can help establish realistic expectations for care management programs.

Indiana State legislators, the Medicaid Director, and the Health Commissioner attended a National Governors Association Policy Academy on Chronic Disease while the State was in the planning stage of its former disease management program. Throughout the implementation stage, the Medicaid agency worked with this group and others in the legislature to inform them of key developments, set realistic goals, and share progress. With their comprehensive understanding of program goals and status, the legislators became natural advocates for the program.

Demonstrated results, such as improved health outcomes, lower program costs, or higher beneficiary satisfaction, can and should be communicated to the legislature and other stakeholders whenever possible. Placing these results within the context of the program and not "overselling" the results is important. Program staff should carefully explain the changes that have occurred and why they matter. When discussing outcomes with elected officials, telling the story succinctly and avoiding jargon is especially important. Moreover, making accomplishments seem "real," perhaps by illustrating successes with examples of enrollees affected by the program, is critical.

Centers for Medicare & Medicaid Services

Program staff also should work with CMS to obtain Federal approval for the program.

Engaging the Media Medicaid care management program staff and agency leadership should develop relationships with the media as a potential tool for building program support. Agency leaders can position themselves as contact persons for the media in cases of potential negative media coverage. If desired, the media can publicize the care management program during the planning stage, help make stakeholders aware of the program, and highlight program successes. Encouraging program champions to write opinion articles in the State newspaper, publish case studies, and provide access to "real people" affected by the program has proven a successful State strategy.

Planning and designing stages. In addition to State approval, the design of the care management program might require CMS formal approval in the form of a State plan amendment or a waiver. Although many States have implemented care management programs, considerable variability exists in program design and Federal authority. Therefore, approval procedures are individualized, usually depending on the program model. As a result, during the planning stage, program staff should work with CMS staff, both at the regional and national levels, even when they are simply soliciting feedback to understand the type of authority that must be used to implement certain care management program components versus others.

Implementation and evaluation stages. Program staff also should maintain contact with CMS after the program is implemented, because CMS can help guide waiver evaluation reports and programmatic changes.

Please go to Section 1: Planning a Care Management Program for additional information on types of approval available from CMS.

Communication Strategies for Demonstrating Program Value

A key challenge for Medicaid staff is communicating the value of care management to a variety of stakeholders—all of whom have potentially different interests. Program staff should identify each of their program stakeholders and their interests and construct messages accordingly. State staff should also determine the appropriate opportunities for publicizing their successes. In some States, program staff have found that operating their program "under the radar" is helpful to allow the program an opportunity to generate success.

Who's Your Audience?

Medicaid leadership and program staff should identify stakeholders, including legislators, senior leadership, providers, and members. Medicaid leadership and program staff should determine what their interests and goals are for the program and provide information accordingly.

What's Your Message?

After Medicaid leadership and program staff determine their stakeholders' interests, they should construct messages accordingly, as shown in Exhibit 2.1. Medicaid leadership and program staff should design a message to reflect why a stakeholder should care about the care management program. A message should provide:

• Context to the problem.
• Story or vivid examples.
• Solutions.
• Action the stakeholder can take.

Exhibit 2.1. Examples of messages for care management programs

Message	Potential Stakeholders	Strategies
Cost Containment	Agency leadership. Governor's office. State legislature.	Set realistic expectations. Discuss slowing growth rate versus decreasing costs. Emphasize improvements in health outcomes. Draw from experiences in other States.
Health Outcomes and Improved Quality	Agency leadership. Governor's office. Other State Agencies. State legislature.	Focus on three to five key measures. Select sound benchmarks. Incorporate within context of overall State chronic disease environment.
Provider Satisfaction	Agency leadership. Governor's office. Media. Providers. State legislature.	Frame care management as a supplemental service for providers. Encourage provider champions to contact their State legislators and Governor's office.
Quality of Life and Patient Satisfaction	Agency leadership. Governor's office. Media. Patients. State legislature.	Communicate anecdotes. Review CAHPS results for population in care management.

Communicating Your Message

Although Medicaid leadership and senior program staff can use many strategies to communicate their message, they should keep in mind that key stakeholders are unable to devote much time to learning about the care management program. Consequently, Medicaid leadership and senior program staff should try to make a positive, memorable impression because they might not receive another opportunity to work with the stakeholders.

To communicate with policymakers, Medicaid leadership and senior program staff should remember to:

• Be clear about the message. Medicaid leadership and senior program staff should focus on being memorable, speaking simply and clearly, and avoiding program jargon.
• Establish relationships. Medicaid leadership and senior program staff should establish relationships before they need them. If stakeholders already know the staff and find them credible sources of information, and if they know why the information staff are reporting is important, they likely will pay more attention.
• Communicate regularly with stakeholders. Medicaid leadership and senior program staff should communicate regularly about program successes as well as about areas that might not be performing as planned. Keeping stakeholders apprised of issues or situations as they develop will help manage expectations of the care management program and build their support.
• Prepare to compromise on certain issues. When approaching policymakers, Medicaid leadership and senior program staff should understand their political needs and try to ensure that at least some of their policy objectives are met.
• Link the care management program to another State initiative that might be more powerful. When appropriate, Medicaid leadership and senior program staff should link themselves and the care management program to other larger or more powerful programs.
• Follow up with policymakers and key staff. After the conclusion of a meeting, Medicaid leadership and senior program staff should follow up promptly with policymakers' key staff to make sure the care management program remains one of their priorities. One way to accomplish this objective is to provide more detailed information in writing about the care management program through brochures and fact sheets.

Conclusion

Engaging key stakeholders is critical to the success of a Medicaid care management program. Involving stakeholders during the planning and designing stages can lead to early buy-in, successful program design, and establishment of long-term support for the program. In many States, stakeholders' long-term support has led to assistance with program expansion and sustainability. Care management program staff and policymakers should not underestimate the value of program champions in designing, implementing, and sustaining a successful program.

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