Appendix:
State Overviews
The
appendix provides a brief description of the 13 States participating in the initial
Learning Network, highlighting many of their successes and lessons learned.
Arkansas
Illinois
Indiana
Iowa
Kansas
North Carolina
Oklahoma
Pennsylvania
Rhode Island
Texas
Virginia
Washington
Wyoming
These
States are among the leaders in their field of care management, and through
their openness and willingness to share lessons learned and productive
failures, they have provided the foundation for the material discussed
throughout this Guide. While each State developed its care management program
to match its unique needs, through the collaboration within the Learning
Network, each State has incorporated significant program improvements.
This
appendix outlines each State's strategies and lessons learned regarding:
- Program
planning.
- Program
design.
- Program
interventions.
- Program
evaluation.
This
Guide and appendix reflect current programs and trends. As care management
programs evolve to meet the changing needs of their populations, States will
continually modify their programs to ensure that they are effectively impacting
their populations. This appendix conveys the experiences of States to date.
Future editions of the Guide are expected to communicate States' experiences as
they implement new program models.
Arkansas: Antenatal and Neonatal Guidelines,
Education and Learning System (ANGELS)
Arkansas began its ANGELS program in February 2002. The program currently
targets pregnant women in primary care case management (PCCM) and fee-for-service (FFS) with a focus on high-risk obstetrics and
neonatology.
Arkansas' Lessons Learned: Gaining Stakeholder Support
- Understand
State legislators' goals and their possible desire to see program results
during their term in office.
- Spend
a significant time engaging stakeholders, particularly in the medical society
and hospital association.
- Emphasize to
providers that the care management program is an added value.
- Distribute
evidence-based guidelines.
|
Program
Planning
The
Medicaid agency began planning ANGELS in partnership with the University of Arkansas for Medical Sciences (UAMS) after determining that when high-risk babies
are born at UAMS, they tend to have fewer complications.
Program
Design
The
Medicaid agency, in partnership with UAMS, designed the ANGELS program, which
involves the State's obstetrical providers in developing best practices for
high-risk cases and helps providers transfer pregnant women with extremely
high-risk cases to UAMS before giving birth. The ANGELS program targets
Temporary Assistance for Needy Families (TANF) mothers and babies in the FFS
and PCCM programs.
Program Implementation
To
develop and share clinical guidelines, Arkansas hosts a weekly teleconference
focusing on high-risk obstetrics for which physicians may receive Continuing Medical
Education credit for participation. An average of 20 to 40 physicians
participates each week at 20 teleconference sites.
Program Interventions
The
ANGELS program offers a call center for physicians and patients, transportation
for pregnant women, and physician guidelines.
- Call Center. The ANGELS call
center operates 24 hours a day, 7 days a week, for physicians and
patients. Primary care providers can consult with specialists regarding
patient management issues, and patients can find support related to their
pregnancy, labor, and delivery, as well as postpartum care. Additional
call center functions include maternal-fetal medicine consults, transportation
arrangements, continuing education, advanced practice nurse consultants,
telemedicine consults, patent education, patient referrals to community
supports, and follow-up calls.
- Transportation. The ANGELS program arranges transportation to UAMS for women with
particularly high-risk obstetric cases. The call center coordinates the
transportation and can arrange for ambulance pickup or a helicopter for
more serious cases. While a patient remains at UAMS for care, her local
physicians receive regular reports from UAMS specialists.
- Guidelines. More than 80 finalized evidence-based guidelines have been written with
physicians. ANGELS staff work with a group of physicians to adapt existing
national guidelines to meet Arkansas' specific needs, especially around
issues of cost, time, research, and clinical expertise.
- Provider activation. State
staff employ a variety of strategies to engage providers in the ANGELS
program. They circulate guidelines, for example, to help providers
recognize and treat symptoms and conditions such as postpartum depression.
In addition, they work with the Arkansas Foundation for Medical Care to
market directly to providers and meet with neonatologists to discuss Level
III neonatal intensive care unit (NICU) admissions.
Program Evaluation
Arkansas is contracting with the
University of Alabama at Birmingham to conduct an evaluation using Medicaid
claims data. In addition, Arkansas Medicaid's External Quality Review
Organization, Arkansas Foundation for Medical Care, conducts the Healthcare
Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of
Healthcare Providers and Systems (CAHPS®) surveys for Arkansas. The program has two
years of data for high-risk pregnancy and neonatology. Finally, UAMS is working
with birth certificate data and Medicaid claims data to analyze ANGELS program
effectiveness on decreased NICU admissions and complications.
Additional Information
Arkansas
Medicaid Web site: https://www.medicaid.state.ar.us/
Return to Appendix Contents
Illinois: Disease Management Program
Illinois' Disease Management Program
started in November 2006, focusing on three populations: aged, blind, and
disabled (ABD) members; persistent asthmatics; and emergency room (ER) users
who have visited the ER more than six times in the last fiscal year without a
hospital admission. The program covers all conditions of the eligible
populations, with special emphasis on five disease categories for the ABD
population: asthma, diabetes, coronary artery disease (CAD), congestive heart
failure (CHF), and chronic obstructive pulmonary disease (COPD). Within Illinois' populations, the program excludes dual eligibles, home- and community-based
waiver clients, and members enrolled in Medicaid managed care.
In-Person Care Management Illinois' vendor has divided the State into 24 catchment areas staffed with
170 "feet-on-the-street" workers. These staff members can be lay health
workers, social workers, or nurses.
The vendor also will place nurses in 10 high-volume
hospitals and lay health workers in 10-12 high-volume clinics to assist with
discharge planning, program outreach, and followup. |
Program Planning
The
goals of Illinois' disease management program are to improve health outcomes,
decrease inappropriate use, and reduce costs. The program was implemented with
an understanding that disease management can improve health outcomes for
members with chronic conditions.
Program Design
Illinois contracted with a
vendor to implement its disease management program. Illinois' vendor assumes
responsibility for improving cost and quality outcomes for all members who fit
into the three population categories. Eighty percent of the vendor's risk is
based on financial savings across all populations, and 20 percent is based on
improvement in clinical indicators in the five targeted diseases.
Program Implementation
Illinois and its vendor are
working together to engage providers. Building on a long history of working
with providers, the State has reached out to physician organizations, nurse
organizations, behavioral health providers, and their sister health agencies.
The program's Medical Director is the most recent past president of the State
pediatric society and is associated with the family practice and medical
associations in Illinois. Physicians will receive no additional payments for
participating in the disease management program.
Program Interventions
All
members receive an introductory letter and educational materials. Illinois' vendor then performs targeted case management, including assessments and action
plans for higher-need members. Moderate-level members receive quarterly
contact, and high-level members receive telephone calls and in-person visits.
Program Evaluation
The State is currently implementing its program
evaluation strategy, which includes establishing the baseline for the financial
and performance indicators.
Additional Information
Illinois
Medicaid Web site: http://www.hfs.illinois.gov/dm
Return to Appendix Contents
Indiana: Indiana Chronic Disease Management Program
Indiana established the Indiana
Chronic Disease Management Program (ICDMP) in 2003 for the State's primary care
case management population. The program members were primarily in the ABD aid
category. Diseases covered included asthma, diabetes, CHF, cardiovascular disease,
and chronic kidney disease. Indiana "assembled" its program by partnering with
local vendors to provide services, including a call center, nurse care
management, and program evaluation.
Building on experience from the
original program and successes in other States, Indiana created a new program,
Care Select, for its ABD population. In November 2007, Indiana signed contracts
with two vendors to provide medical homes, utilization management, prior
authorization, and care management services as appropriate to approximately
70,000 members. Indiana seeks to provide comprehensive care coordination to
this previously unmanaged population.
Program Planning
In
November 2002, as part of the early conceptualization for ICDMP, Indiana's Medicaid Director, the Indiana Department of Health Director, and two State
legislators attended a National Governors Association Policy Academy on disease management and met with Dr. Ed Wagner, who is the director of the
Macoll Institute for Healthcare Innovation and lead developer of the Chronic
Care Model. The Policy Academy provided the necessary impetus for program
development, including legislative buy-in.
Program Design
Indiana decided to assemble its
ICDMP program by partnering with local agencies to provide chronic disease
management services. The main components of the program are as follows:
- Program
Management. Medicaid and the Department of Health jointly assume responsibility for
managing the program.
- Primary
Care. Members are assigned a primary care provider who serves as the focal point
of patient care.
- Care
Management. Members have access to care management via in-person nurse care managers
or the call center based on stratification.
- Patient
Data Registry. An electronic data registry is available to Medicaid providers and care
managers.
- Measurement
and Evaluation. Indiana conducted a statewide evaluation and a randomized controlled
trial.
Indiana also partnered with
AmeriChoice for the call center, the Indiana Primary Health Care Association
for nurse care managers, and the Regenstrief Institute for help with member
stratification and program evaluation.
Program Implementation
Approximately 30,000 members have received
disease management services through ICDMP. Eligible members, who are identified
through Medicaid claims data, are stratified into either high-risk or low-risk
groups, but they can move in and out of high-risk and low-risk management. Indiana developed its patient stratification methodology internally with assistance from
the Regenstrief Institute. Factors that drive patient stratification include
historical claims data, referrals (by patient, physician, or call center), new
costs (e.g., hospitalization), and pharmacy utilization.
Program Interventions
ICDMP interventions include a call center, care
management, provider collaboratives, and provider toolkits. The call center
monitors patient status and follows up based on established protocols. Call
center staff assume responsibility for:
- Letters
to patients and physicians.
- Outbound
calls to assess, inform, and motivate.
- Patient
education materials.
- Inbound
calls.
The
nurse care managers provide more intense followup and support to high-risk members.
The care management intervention typically lasts 4 to 6 months. During this
time, nurse care managers provide disease education and help patients set
self-management goals. They also help foster the patient's relationship with
his or her primary care provider. After 4 to 6 months of care management,
patients "graduate" from the program and receive followup calls every 3 months
from the call center.
Indiana's Lessons Learned: Evaluation
- Randomized
controlled trials allow for validation of intervention effects.
- Disease
management programs require time to exert an impact.
- Measuring
member satisfaction is important.
- Measures
should be planned strategically.
|
For
providers, Indiana offers ongoing education, training, toolkits, and nurse care
manager support. In addition, at the beginning of the program, Indiana conducted provider collaboratives, including three learning sessions followed by
action periods that allowed for implementing new practices. Teams implemented
practice-site improvements and reported results to the State.
Program Evaluation
The
State legislature mandated a program evaluation when Indiana created the
program. To ensure the study's legitimacy, the State decided to use an outside
evaluator, the Regenstrief Institute. The study included a random control trial
within the Indianapolis population and a time-series evaluation comparing
patient care in different parts of the State. Data was collected from:
- Collaborative
learning sessions.
- Medicaid
administrative claims.
- Electronic
medical records (Central Indiana only).
- Care
management vendors.
Evaluation
results found that the program reduced expenditures for patients with CHF but
might increase expenditures modestly for diabetics.
Additional Information
Indiana
Medicaid Web site: http://www.indianamedicaid.com/ihcp/index.asp
Indiana
Care Select Web site: http://www.indianamedicaid.com/ihcp/HoosierHealthwise/rbmc_index.asp
Indiana
Chronic Disease Management Program Web site: http://www.indianacdmprogram.com/
Return to Appendix Contents
Iowa: Care Management Program
Iowa's care management
program, established in July 2005, covers members with asthma, diabetes, and
CHF, as well as high-utilization and high-cost members. The Iowa Foundation for
Medical Care (IFMC) operates the program as part of a larger contract with Iowa
Medicaid.
Electronic Medical Records Iowa has developed an in-house online
health information tool, the Iowa Electronic Medical Records System for
physicians and hospitals. The system contains claims and pharmacy data
updated weekly. Iowa worked closely with its provider community to test the
system and gather feedback. |
Program Planning
Iowa developed its program
to provide optimal care to all Medicaid members. Program goals include:
- Improving
access to care and eliminating unnecessary care.
- Increasing
member involvement in care through self-management skills.
- Using
community resources efficiently.
- Improving
clinical outcomes.
- Saving
program money.
Iowa's Medicaid program is
operated through the Iowa Medicaid Enterprise, a collection of nine vendors
that collaborate with the State to accomplish program goals. The vendors work
in the same building with State staff and strive to provide Medicaid services
seamlessly. As one of these vendors, IFMC runs the State's care management
program. In 2003, before the creation of the Iowa Medicaid Enterprise, IFMC
operated a State diabetes pilot program that provided lessons about operating
and evaluating care management programs.
Program Design
Iowa's asthma program launched
in July 2005, its CHF program in October 2006, and its diabetes program in
December 2006. The State chose to implement the asthma program first because
staff believed asthma would render the best initial return on investment. The
program is opt-in, which has made enrolling members difficult due to trouble
contacting them.
Program Implementation
Using claims data, Iowa identified 1,312 asthmatics with high
costs and inappropriate use patterns for program outreach. The State attempted
to reach this group through telephone calls but, after repeated attempts, had
reached only one-third of the asthmatics. Iowa then sent letters to the
identified group, but enrolled only 17 members through this method. Program
staff realized that to enroll their target population of 250 members, they
would have to open enrollment to the entire population of asthmatics. This
decision led to their enrolling 266 members.
Iowa also has
also worked to involve providers in the program, with engagement activities such
as creating
a Clinical Advisory Committee of physicians throughout the State and extending outreach
to provider organizations. The standing Clinical Advisory
Committee 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.
Program Interventions
Although
disease-specific interventions vary for asthma, diabetes, CHF, and high
utilizers, all members receive telephonic care management and educational
materials. Disease-specific interventions include providing peak-flow meters to
members with asthma and providing Pharos (a telephonic reporting system) for
members with CHF. Iowa is working with Des Moines University to provide the
Pharos system. As part of the Pharos intervention, members call the system
every morning and answer five questions about their CHF health status (e.g.,
weight, shortness of breath, swelling). If the member's answers indicate a need
for further assistance, a care manager calls the member.
Program Evaluation
Iowa has completed an
evaluation for the first year of its asthma program, including a description of
the program and interventions, participating members' demographic data, program
costs, and program outcomes. In addition, IFMC creates monthly
reports on the care management program that cover enrollment,
contact data, and information on services provided to specific patients. Iowa also measures pharmaceutical utilization, emergency room utilization, and inpatient
admissions.
Additional Information
Iowa
Medicaid Web site: http://www.ime.state.ia.us/
Iowa Diabetes Pilot
Evaluations: http://www.ime.state.ia.us/ManagedCare/ManagedCareDocs.html
Return to Appendix Contents
Kansas: Enhanced Care Management Program
Kansas began enrolling
Medicaid PCCM members in its pilot care management program in March 2006. The
program serves high-need PCCM members in Sedgwick County, the State's most
populous county. Although the program currently has fewer than 200 members, it
is expanding. Serving identified high-risk Medicaid beneficiaries, the program
provides disease-specific management for asthma, diabetes, CHF, and other
conditions.
Stakeholder Support Because
of budget constraints, Kansas' program was nearly discontinued in August
2006. However, response from the community and local physicians created
enough support to reverse the decision to cancel. Kansas staff would advise
other States to seek and maintain a higher level of visibility for the
program early to build a positive reputation within its own agency and the
State. |
Program Planning
Following
a recommendation by the State legislature, the Kansas Medicaid agency decided
to implement a care management pilot program as a cost containment and quality
improvement measure. Before implementation, Kansas carefully reviewed care
management options and data from its population. The State decided to focus on
a care management program to develop an administrative program coordinating a
broad range of services allowing for Medicaid beneficiaries' "whole health."
Kansas chose to pilot the program in Sedgwick County because of its large
concentration of patients, established PCCM program, strong legislative support,
presence of a viable local vendor—Central Plains Regional Health Care
Foundation (Central Plains), and a supportive medical society. The pilot was
originally designed to operate for 5 years, but due to budget constraints it
will operate for 2½ years.
Program Design
Kansas partners with Central
Plains to deliver care management to PCCM members who choose to participate in
the Sedgwick County project. The vendor is a nonprofit organization that also
manages Project Access to connect the uninsured with donated community health
services. Central Plains' long-term relationship with providers and its
connections to the Medical Society of Sedgwick County proved instrumental in
helping the State secure provider buy-in for the program.
State
staffing limitations compelled Kansas to partner with a vendor. Central Plains'
enhanced care management staff includes four nurse care managers for
approximately 200 members. Each nurse care manager has a maximum caseload of 60
members. To assist the nurses, the State also employs a disease management
specialist nurse, whose maximum caseload is 150 members, and two community
resource care managers with a social service background.
Program Implementation
Kansas uses the Johns Hopkins Adjusted Clinical Groups
Case-Mix predictive model to identify patients and stratify members for the
care management program. After patients are identified, Central Plains contacts
the potential enrollees for voluntary enrollment. Interventions, which vary,
are based on member-identified needs, PCCM-identified needs, and utilization
history.
Initially,
Kansas faced difficulty recruiting members for the program. Eligible patients
first are sent an invitation letter for the program, after which care managers
attempt to reach them at least three times by phone.
To
increase enrollment, Kansas expanded its criteria for potential members.
Medicaid staff have visited the Central Plains office many times to review
cases and program operations. Through these site visits and work with Central
Plains, the State has been able to encourage a focus on the project's clinical
outcome aspects.
Program Interventions
Kansas bases its interventions on the use of an
interdisciplinary team of nurse care managers and social service specialists.
Interventions include in-person and/or telephonic care management, connection with
community supports, collaboration with the PCCM program, and provider and
patient education materials.
Program Evaluation
Kansas is contracting with an external evaluator to
conduct an evaluation of the care management pilot program. The claims-based
evaluation will compare the program to a reference group in a similar Kansas county. When designing the evaluation, the State, external evaluator, and Central
Plains met to discuss the evaluation philosophy and goals and to set measures.
Central Plains also has implemented its own internal evaluation to assess
patient health and program outcomes.
Additional Information
Kansas
Medicaid Web site: https://www.kmap-state-ks.us/
Return to Appendix Contents
North Carolina: Community Care of North Carolina
North
Carolina Medicaid operates a statewide enhanced PCCM program, Community Care of
North Carolina (CCNC). Implemented in 1998 and built on a traditional PCCM
program (Access), CCNC currently has approximately 745,000 Medicaid beneficiaries.
North Carolina's program is based on local physician networks responsible for
the local leadership of the enhanced care management programs.
North Carolina's Lessons Learned: Provider Engagement
Involve
physicians early in the planning process.
Seek physician
input in measurement and in creating care guidelines to obtain physician
buy-in.
"Sell" the
program to providers as a tool that can support their efforts to manage
patient care.
Recognize that
physician leaders can be your best advocates with the State legislature and
with other providers.
Recognize that
Physician Advisory Groups can provide valuable input and help gain provider
buy-in. |
Program Planning
Before
the implementation of CCNC, the majority of North Carolina's Medicaid
population was enrolled in Access, the State's PCCM program. Although the purpose
of Access was to provide every enrollee with a medical home, it was not
intended to serve as a holistic care coordination system for a large
population. CCNC was developed to help primary care providers manage the
Medicaid population's health care needs and improve the quality of their care.
CCNC's gradual development allowed the provider networks time to create
effective programs and show positive results without legislative scrutiny.
Program Design
North
Carolina's
program includes 14 physician networks. Unique in terms of structure, community
partners, and project activity, each CCNC network was designed locally,
allowing it to best fit the needs of its region. Each network must collaborate
(via a business associate agreement) with the local health department,
department of social services, and hospital or hospitals. The CCNC networks
range in size from 17,000 to 180,000 members and receive $2.50 per member per
month from the State for administrative and operation costs. Network physician
leaders came to a consensus to concentrate care management and quality
improvement efforts initially on asthma, diabetes, high ER utilization, and
high-cost patients, based on inpatient hospitalization data and ER utilization.
Currently, CCNC is expanding its care management and quality improvement
program to cover CHF statewide. Individual networks manage other chronic
illnesses, including obesity, attention deficit hyperactivity disorder, COPD,
mental health integration, and sickle cell anemia.
Program Implementation
To
build the CCNC networks, North Carolina relied on the unique strength of its
physician community and the appeal of locally run programs. The first step in
CCNC's network creation was to garner physician participation and buy-in by sending
letters to primary care providers who serve more than 2,000 PCCM patients
introducing them to the program's concept and asking them to participate. North Carolina then worked through an informal request for proposal (RFP) process with the
interested primary care providers and other community Medicaid providers.
Finally, the State partnered with local stakeholders to finalize program
implementation.
Program Interventions
Networks
provide all beneficiaries with a medical home and a toll-free call center and selected
beneficiaries with care management. Beneficiaries are selected for care
management using claims data stratification (identification of high-cost
beneficiaries with chronic conditions) and provider referrals. For high-intensity
patients eligible for care management, care managers first call or send a
letter introducing themselves. The care manager reviews the patient's chart, conducts
a four-page assessment, and talks with the family, especially if the patient is
a child. Finally, the care manager develops a plan of care with the patient. Assigned
to physician offices, care managers help ensure that patients make and keep
their appointments. Care managers work closely with the physician and attend
physician office staff meetings to become part of the office team that manages
patient care.
Program Evaluation
Since
program inception, CCNC has collected data and monitored financial, quality, and health outcomes.
CCNC conducts both claims and chart audits to review outcomes and
process data and measures. The CCNC program office assumes responsibility for collecting a
range of outcome measures via claims analysis (e.g., inpatient admission rate)
and performance and process measures via randomized chart audits (e.g.,
implementation of an asthma action plan). Each network has a medical committee
consisting of participating primary care providers that reviews evidence-based
guidelines and Medicaid claims data to make recommendations to the clinical
directors. State program staff meet regularly with the network clinical
directors in finalizing the performance measures for the program. This process
helps ensure physician buy-in and support for the measurement process. North Carolina has contracted with the University of North Carolina's Sheps Center for Healthcare Research and Mercer Consulting to evaluate program outcomes and savings.
Additional Information
North
Carolina Medicaid Web site: http://www.dhhs.state.nc.us/dma/
Community
Care of North Carolina Web site: http://www.communitycarenc.com
Sheps Center Evaluation:
http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf
Return to Appendix Contents
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