Managing Care for Adults with Chronic Conditions

Using Managed Care Networks

The most intensive interventions currently being implemented by states include programs that combine acute and long term-care-services that are funded by Medicaid and Medicare and that use managed care networks to fully integrate care. These models use interdisciplinary care teams and comprehensive provider networks to coordinate care across payers, settings, and service providers.

The Wisconsin Partnership Program (WPP) and VNS Choice are two comprehensive programs that serve Medicaid beneficiaries who may be elderly or adults with disabilities, including dual eligibles. Both programs integrate health and long term support services, including home and community based services, physician services, and other medical care.

Table 1 presents a comparison of components of the WPP, VNS Choice, and Service Options Using Resources in a Community Environment (SOURCE) programs.

• The Wisconsin Partnership Program (WPP) serves frail elderly age 55 and older, and adults with physical disabilities. Participants must be eligible for Medicaid and have complex medical conditions in need of a nursing home level of care. The program combines home and community-based services with physician services and all medical care. Medicaid and Medicare financing are integrated. Benefits are capitated and paid to four nonprofit community-based organizations serving six counties in Wisconsin. Total enrollment is 1,329.

  Most services are delivered in the member's home or in a setting of his or her choice. An interdisciplinary team provides care management. The member is at the center of the team which also consists of a registered nurse, social service coordinator, a nurse practitioner, a primary care physician, other appropriate specialists, and natural supports.

  Utilization of services among WPP members with prior Medicaid history has been substantially reduced after enrollment in the program. Hospitalizations and emergency room visits for ambulatory care sensitive conditions (ACSCs) were within projected limits. Primary care physicians expressed a high degree of satisfaction with the program.

• VNS Choice is a managed long-term care plan, under contract with the New York State Department of Health, that began in 1998. It is one of 14 managed long-term care programs and enrolls nearly 3,000 individuals in New York City. Members are Medicaid eligible frail elders, age 65 and older who are nursing home eligible. Ninety-nine percent are also dually eligible for Medicare.

  Regionally based care management teams manage and coordinate enrollment. A nurse consultant is care manager and provider of skilled home care. Teams include social workers, rehabilitation therapists, member service representatives, nurse practitioners, and paraprofessionals. Non-home care services are provided through a network of contracted community-based providers. Team members and families, physicians, and network providers work in close collaboration with one another.

  While not financially responsible for the costs of hospital care, VNS Choice has a financial incentive to reduce member hospital admissions and length of stay and to insure adequate discharge planning. Care management by VNS Choice has resulted in decreases in member hospital admission rates, emergency room utilization, length of stay, days per thousand, and percent with one or more admission a year.

Table 1. Comparison of Integrated Care Coordination Models

	New York VNS Choice	Wisconsin Partnership Program	Georgia SOURCE Program
Financing	Partially-capitated Medicaid	Fully-capitated Medicaid and Medicare	Primary Care Case Management (PCCM) Medicaid
Physician	Maintain primary care provider (PCP)	Provider Network	Provider Network
Population	Elderly adults	Physically disabled and elderly adults	Physically disabled and elderly adults
Eligibility	Nursing home level of care	Nursing home level of care	Have a chronic condition

Current as of October 2003

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Internet Citation:

Managing Care for Adults with Chronic Conditions. Workshop Brief, User Liaison Program, December 11-13, 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/chronic/ulpchron.htm

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