Resource centers offer face-to-face support

Staff build relationships with Medicaid recipients

It's not unusual for Medicaid recipients to walk into one of WellPoint's community resource centers and ask for help in getting an appointment with a provider, arranging transportation or child care for a medical appointment, or to find out information about a chronic condition.

WellPoint's 22 community resource centers in seven states enable the health plan's multidisciplinary staff to build relationships with its members and to work community agencies to help meet members' needs.

"We know that the Medicaid population has complex lives and so many challenges that developing a trusting relationship is an important part of getting them to adhere to their medication regimen and their treatment plan. Having a presence in the community allows us to develop trust and break down some of the barriers," says Nancy Atkins, MSN, RNC, NP, vice president of state-sponsored business for WellPoint.

The state-sponsored business division serves members with low incomes or high-risk medical conditions who are eligible for publicly funded insurance.

WellPoint's community resource centers have diverse staff who match the demographics of the community. For instance, in areas with a large Hispanic population, the staff include employees who are fluent in Spanish as well as English.

"We help members in a lot of different ways in addition to their health care needs. We work with community organizations to help the members find help with housing, job placement, childcare, and other needs. We partner with community agencies and serve on their boards so we will know where the resources are to help meet all the needs of our members," she says.

To raise awareness of its services in the community, WellPoint offers classes at the centers, makes their conference room and meeting rooms available for community meetings, and maintains a group of computers that residents may use to access the Internet.

The staff at the community resource centers work as a team to help members learn to navigate the health care system and work to remove barriers to compliance, whether the member needs education about a condition or assistance with child care, transportation, or housing.

The company brings together staff from all the community resource centers once a year to share best practices and learn new skill sets.

The staff at most centers include clinical quality nurses who provide clinical care coordination, outreach specialists who can help members find community services, health promotion consultants who conduct education for members and the community, and nurse case managers who coordinate the care of members with complex needs.

The outreach component

The services that the community resource centers provide goes beyond traditional health plan coverage, Atkins says.

Recently, a teenage boy who was covered by a WellPoint health plan for Medicaid beneficiaries walked into the insurer's community resource center in his neighborhood and asked for help. His mother, who was preparing for a bone marrow transplant as part of her cancer treatment, was in an isolation unit at a university-based hospital in a distant city and the boy wanted to see her.

The outreach specialist at the center worked with the hospital to set up a time for him to visit, set up transportation, and arranged for him to stay at a Ronald McDonald House.

Members receive an outreach call when they join the plan, educating them on all of the benefits that are available to them and urging them to call or come into the center if they need help.

The medical management and pharmacy departments analyze claims data regularly to identify members who haven't filled their prescriptions, who are newly diagnosed with a chronic condition, or whose claims data indicate a problem.

Providers often call the resource center if a member misses an appointment or hasn't brought her baby in for a well child visit and immunizations.

"Those are the red flags that indicate that someone needs an outreach. The team works together to investigate what is going on," Atkins says.

The team starts by trying to contact the member using the address and telephone number in the files. If the member no longer is at that address or the number has been disconnected, they may contact a community agency that has worked with the member for help in getting an address.

The person who gets in touch with the member may be the outreach specialist, clinical quality nurse, or case manager, depending on the situation. If the health promotion consultant is going to be in the community for an educational activity, he or she may be the person who tries to locate the member.

Case management is a mix of telephonic communication and face-to-face visits. For instance, if an elderly person hasn't shown up for a doctor's department or gotten a prescription refilled and the team can't reach him or her on the telephone, a team member will go out to check on the beneficiary.

If a case manager is working with a mother whose baby isn't gaining weight, she may visit the home to find out what is going on.

"If we don't get a response, we may need to go out into the community and find out what is going on," Atkins says.

When members are hospitalized, the case management nurses work with the case managers in the inpatient setting to help members navigate the system and to ensure that their discharge needs are met.

Each community resource center has a unique community-based model designed to meet the needs of that community and to comply with the different benefit packages and eligibility requirements of each state, Atkins says.

"The vision for this program is for us to be a partner in the community so we understand and know our members and their unique needs," she says.

For instance, some states require case management for certain populations, such as those with pediatric asthma. In those cases, the community resource center staff conduct outreach to members in those targeted populations as well as work to meet the needs of members who ask for help.

Because obesity is a huge problem in West Virginia, the community resource centers in that state have implemented several programs, including a collaboration with Weight Watchers to provide services for members, worked with providers to raise community awareness of obesity, and trained providers to measure body mass index of their patients.

Last year, WellPoint opened 11 new community resource centers, bringing the total to 22.

"Having a presence in the community helps us meet the needs of our members. An 800 number just doesn't work with this population," Atkins says.

(For more information, contact Leslie Porras, Wellpoint's public relations director, e-mail: Leslie.Porras@wellpoint.com.)