Choosing Care Management Interventions

Once a State is aware of the menu of care management interventions, its next step is to choose the interventions that best fit its target population, resources, and goals. A State should consider several factors when choosing interventions:

• Evidence base of interventions.
• Program budget limitations.
• Program model (buy, build, or assemble).
• Provider and member interventions.
• Diseases covered (e.g., asthma, diabetes).
• Stakeholder input.

States must balance all of these factors to choose the set of interventions appropriate for their situation. Balancing the costs and benefits of interventions can be difficult.

Evidence Base

A strong evidence base can help a State defend its program against critics until the program has had time to show positive outcomes. The evidence base can come from literature or from other State Medicaid experiences. The literature offers some evidence on the efficacy of care management interventions, although often not Medicaid-specific evidence. The literature review in Section 8: The Care Management Evidence Base identified a few important findings across diseases.

• Intervention effectiveness varies among diseases. Interventions vary across diseases in overall efficacy and in their ability to impact particular outcomes. For example, the literature review found that telephonic care management was more effective for asthma than for diabetes.
• In-person care management. In-person care management was the most effective intervention across all diseases addressed in the literature review. Though in-person care management can be more difficult and expensive to implement, in-person care management is the best intervention to use to generate cost savings and improved clinical outcomes.
• Provider interventions. As expected, provider interventions had the greatest impact on measures that target provider processes such as HbA1c screening or medication use. States can use provider interventions to impact process measures or, in some cases, utilization or cost, but provider interventions had minimal impacts on clinical outcomes overall.

Intervention Costs

Interventions vary in cost as well as in efficacy and speed. Some interventions might seem appealing (e.g., sending a nurse care manager to the home of every member) but are infeasible due to cost constraints. Considering the cost of interventions in relation to the benefits is important. Exhibit 4.2 shows the estimated average cost (low, medium, high) of interventions.

Exhibit 4.2. Intervention cost estimates

Intervention Type	Intervention	Cost
Provider
	Evidence-Based Guidelines and Protocols	Low
	Provider Education and Training	Medium
	Practice-Site Improvement	Medium
	Call Center	Medium
	Provider Profiling and Reports	Low
	Registries and Clinical Information Systems	High
	Telemedicine	High
	Electronic Medical Records, Decision Support, Reminder System, and Other Electronic Communication Systems	High
	Provider Incentives	High
	Member
Self-Management Education		Medium
Educational Brochures, Mailings, and Member Letters		Low
Call Center		Medium
In-Person Care Management		High
Telephonic Care Management		Medium
Self-Monitoring Devices		High

If the State contracts with a vendor to provide care management services, the cost of particular interventions might be less important, because most costs are incorporated in the overall contract or PMPM fee.

Program Model

A State's care management model—buy, build, or assemble—can influence the interventions the State chooses. Please go to Section 5: Selecting a Care Management Program Model for additional information on care management models. If a State chooses to procure the program with a vendor, the interventions the vendor can provide might be limited. The State also might have to work with the vendor to adapt the interventions to fit the needs of the State's program. In an assemble model, the State uses a combination of partnership and contracting to organize a program. If a State assembles its model, adding interventions might prove difficult because doing so might require contracting with additional specialized vendors. In a build model, the State primarily uses in-house staff to administer the program and conduct interventions. In this case, the State might be limited by its own lack of capabilities or resources. For example, the State itself might be unable to support the use of self-monitoring devices or telemedicine.

Stakeholder Input

Throughout the process of planning, designing, and implementing a care management program, gathering stakeholder input is important. Stakeholders can be members, providers, advocates, caregivers, legislators, or other government agencies. In relation to interventions, stakeholder input can prove vital to gain buy-in from members and providers. States have formed physician advisory boards and regional advisory councils to solicit provider and member input. Please go to Section 2: Engaging Stakeholders in a Care Management Program for additional information on stakeholder input.

Implementing Care Management Interventions

States must decide who will receive interventions and how they will receive them. To do so, States must identify the population that will benefit from the interventions, coordinate the delivery of provider and member interventions, and address the specific barriers the Medicaid population faces.

Target the Appropriate Population

Factors that might influence decisions regarding which members will receive which care management interventions include cost, resource availability, and members' potential benefit from the intervention. A State might wish to provide every diabetic member with a care manager, but the cost would be prohibitive. Instead, the State might stratify members so individuals with the most severe diabetes receive care management and diabetics with less severe diabetes receive disease education materials. In addition to cost, States must consider which members will benefit most from interventions. Care management might exert a significant impact on a patient who is experiencing difficulty managing his or her congestive heart failure (CHF) and a minimal impact on a patient who is self-managing his or her CHF successfully. Given limited resources and potential benefit to patients, States generally choose to give more intense interventions to high-risk or high-cost members. Please go to Section 3: Selecting and Targeting Populations for a Care Management Program for additional information on techniques for risk stratification and predictive modeling, both of which can be used to determine the level of intervention a member needs.

Pennsylvania's care management program features three levels of care. At Level One, members receive educational mailings and access to the nurse call line and audio health libraries. A patient at this level receives a call from a nurse care manager at weeks 6 and 26. At Level Two, a patient receives all Level One services plus more frequent calls from a nurse care manager. The patient might be referred to primary care case management (PCCM), in which case the patient's provider is notified that he or she is receiving care management. At Level Three, patients are provided with all Level One and Level Two services plus in-person visits and a more intensive call schedule. Pennsylvania's vendor, McKesson, employs a proprietary risk stratification methodology to place members in each level. Members are able to move between levels, as needed.

Facilitate Provider and Care Manager Coordination

In the most effective care management programs, care managers and providers deliver the same messages to members. Because member interventions are delivered most frequently by a care manager, often the coordination must take place at the care manager to physician (or physician office) level. If a member is receiving the same information from the care manager and the physician, his or her behavior is more likely to change. States can use several techniques to coordinate provider and member interventions:

• Station nurse care managers in provider offices.
• Inform providers of member interventions.
• Provide patient registries to nurse care managers and providers.
• Work with office staff.
• Develop a system for providers to refer patients for care management.
• Identify patients in a practice who, based on initial claims analysis, might benefit from care management activities, and coordinate efforts with practice staff.
• Station care managers in safety-net hospitals during peak Medicaid use times.

Nurse care managers can work with provider offices to inform physicians of the care management interventions their patients are receiving and to ensure the patient is receiving a consistent message.

In North Carolina, nurse care managers assume responsibility for managing patient care at a set of physician offices. Nurse care managers become familiar with each physician practice, sometimes attending physician office staff meetings and joining the office team that manages patient care. The physician is familiar with the nurse care manager and feels comfortable communicating with him or her about patients and making patient referrals.

Rhode Island is creating a new care management program that will assign nurse care managers directly to large practices with 150 to 200 Medicaid-only adult patients who are determined by the State's Connect CARRE predictive modeling algorithm to be at moderate risk or high risk. The first site will be a federally qualified health centers (FQHC), and the nurse care managers will manage the care of moderate- and high-need individuals there. Rhode Island is moving toward integrating nurse care managers into the practice so they will remain a constant part of patient care teams.

The State can also use patient registries to facilitate communication between providers and nurse care managers. States have employed systems that allow physicians and nurse care managers to enter information on patients (e.g., notes from a call, an HbA1c level) and to see claims data. In addition, States can use other forms of communication to inform providers of care management activities. When launching their programs, States often send materials to providers that contain background information on the care management program and its interventions. Members benefit when their providers are aware of and support care management efforts. To achieve program success, implementation of both provider interventions and member interventions is critical.

Address Barriers to Care Delivery

As States implement interventions, they should consider the challenges that other States have faced in implementing care management programs. Typically, the Medicaid population is poorer, less educated, and sicker than the privately insured population. To maximize success, States have adapted their programs to best communicate with members and coordinate social services.

Communicate with members. Because member telephone numbers and addresses in Medicaid data often are incorrect, care management program staff should expect that contacting members will be difficult. States might set limits on the number of times they will attempt to contact members.

In Indiana's initial program, ICDMP, call center staff attempted to reach members three times (on different days and times) and sent the members a welcome packet. If the call center failed to reach a member, he or she was put into a queue for 3 months, after which staff again tried to reach the member three times. If the call center was unsuccessful again, the member was returned to the queue and sent educational materials. This pattern continued until the call center reached the member or until the member was no longer eligible for the program.

Public distrust of Medicaid or of public programs also might make contacting members difficult. Indiana found that members were not opening letters from the care management program because the envelopes had the same logo as the Medicaid program. When Indiana changed the envelopes to have a care management-specific logo, members were more likely to open them.

In addition to difficulties reaching Medicaid members, States must expect that many members will have low literacy levels. Materials should target an appropriate reading level and be made available in prominent languages. Some States might want to consider holding informal focus groups with select Medicaid members to determine the best mechanism for communication with them and "perceived barriers" to communication.

Connect members with other supports. To serve a Medicaid member, care management programs often have to address his or her other social issues. Competing priorities, such as adequate housing or food, can make taking care of their health difficult or impossible for members. Medicaid care management programs can serve as a link to many services, including behavioral health services, transportation, food stamps, and support groups.

Rhode Island developed an online system, Ask Rhody, that members and care managers (and all other Rhode Islanders) can use to find member services and to check for member eligibility for certain benefits. The system is available in English, Spanish, and Portuguese. Using a Real Choice grant from the Centers for Medicare and Medicaid Services, Rhode Island's Department of Human Services developed this Web site in collaboration with other departments within the Rhode Island Office of Health and Human Services. Among services listed are housing assistance, homeless shelters, adult daycare, counseling centers, food centers, family services, support groups, and rehabilitation centers.

The link to behavioral health services can be particularly important for the Medicaid population. Depression is especially pertinent, because depression rates are two to four times higher among low-income and Medicaid-insured patients. Care management programs can refer members to mental health specialists or even assess a member's mental health status.

Indiana's initial program, ICDMP, operated a call center that used the Patient Health Questionnaire (PHQ) to assess member depression. During an assessment, call center staff asked two questions:

1. "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and
2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"

If the member gave a positive response to either of the two questions, call center staff continued with the remaining PHQ screening. If a member scored 10 or higher on the PHQ, staff prompted the member's provider by mail to ask that he or she carefully consider followup testing, and care. Indiana call center staff also were trained to recognize "red flags," which would result in their transferring the call to a supervising nurse or placing a call to the member's provider.

Iowa has worked with its Managed Behavioral Health Organization (MBHO) to set up links between care management and behavioral health providers. Iowa care managers administer the PHQ-2, a depression screening tool, to every member enrolled in the Medicaid care management program. If a member answers either question affirmatively, the care manager continues with the PHQ-9. Depending on the PHQ-9 score, the care manager coordinates with Iowa's MBHO to arrange for services or more frequent testing. If the member's score indicates severe depression, the care manager refers the member to the mental health vendor's crisis line and arranges for an immediate or next-day appointment.

Patient Health Questionnaire Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. Feeling down, depressed, or hopeless. Trouble falling or staying asleep, or sleeping too much. Feeling tired or having little energy. Poor appetite or overeating. Feeling bad about yourself–or that you are a failure or have let yourself or your family down. Trouble concentrating on things, such as reading the newspaper or watching television. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual. Thoughts that you would be better off dead or of hurting yourself in some way.

Conclusion

Choosing interventions constitutes an important part of designing a care management program. States should be aware of the spectrum of interventions and other States' experiences with interventions. Once a State is aware of the intervention options available, it must determine which interventions are appropriate for its population and program. States must make decisions based on their vendor or in-State capabilities, financial capacity, timeframe, and the evidence base. Interventions must also be adapted to the Medicaid population; communication and social supports are particular issues for these individuals. Understanding the potential impact of the care management interventions feeds into the evaluation process.

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