CM program serves young Medicaid beneficiaries

Program targets ill members ages 6 months to 21

A multidisciplinary care management program for young Medicaid beneficiaries with complex conditions has resulted in significant increases in members' use of effective treatments and services.

In the first year of the program, administered by CareSource, the percentage of children using appropriate asthma medications rose from 50% to 57% and well child visits increased among all age groups, earning the health plan a rating of excellent from the Ohio Department of Job and Family Services.

The program started in 2001 in response to a new state requirement to promote case management for chronically ill children in the Medicaid population.

"As part of our mission to help the under-served population, CareSource has always offered case management services to its members but expanded the program to meet the state requirements. When the state specified providing case management for members ages 6 months to 21 years with special health care needs, we expanded the program in-house and hired case managers who specialize in conditions such as prenatal care and asthma management," says Daniel Paquin, COO of the Dayton, OH-based Medicaid managed health care plan.

The department includes asthma educators, diabetic educators, prenatal-care specialists, and behavioral health specialists. "We have included case managers who are experienced in a variety of areas so we can provide the best possible care coordination for our members," Paquin adds.

Members in the program have chronic diseases that range from asthma and sickle cell disease to depression. A sizable percentage of members in the program are pregnant teenagers. "Unlike members in a commercial plan, the individuals in our programs have a complex array of psycho-social needs, along with multiple chronic conditions with multiple comorbidities," Paquin adds.

Population is a tricky one

Medicaid members provide a challenge for case managers because the population is transient, often changing addresses, and they may not have telephones, says Mia Lowe, RN, CCM, CCP, director of case management.

"We utilize a lot of different forms to reach members, including calling providers and contacting pharmacies to get current addresses and phone numbers, as well as reaching out to members with postcards asking them to get in touch," she adds.

Many of the members have social issues along with their medical needs, she adds.

Attending to social needs first

"They may have trouble affording food and clothing or may be about to be evicted because they can't pay their rent. We have to take care of these needs first, before we can start helping them manage their health," Lowe says.

A team of social workers, one of whom is bilingual, team with case managers to help manage the needs of the members.

"We help them first with their social needs. If they are worrying about finding food or staying in their home, they're not going to take care of their health care problems," Lowe adds.

The social workers are familiar with community resources throughout Ohio and can help members get connected to programs and agencies in their communities that can meet their needs. If needed, the case manager can bring in a social worker or a behavioral health case manager to help meet the member's needs. If the member has trouble with medication compliance, the case manager can refer him or her to the pharmacy department for help.

About 6% of the members in the Covered Families and Children Program need case management, says Candice M. Freil, RN, EMBA, MHA, senior vice president of care management.

When new members enroll in the program, a CareSource nurse calls the parent or guardian and administers a health questionnaire to identify the presence of health conditions that require ongoing care. If the child has any of the conditions, the case is referred to a case manager who calls the parent or guardian and conducts an assessment to determine if the child is appropriate for case management.

Other members are identified through claims data analysis, referrals from local physicians and emergency departments, medical management staff, the health plan's 24-hours nurse advice line, and the on-site nurse liaison who is located at one of the hospitals with the largest volume of patients served by CareSource.

When a child is enrolled in the case management program, a nurse case manager calls the parent or child if he or she is old enough, providing education about the condition. The case manager works with the parent or child to set health care goals and to develop an individualized care plan and shares the plan with the patient's primary care physician for input and follow up.

"In addition to the initial assessment when they enroll, if the members need case management, we conduct a more thorough disease-specific assessment and get the provider involved in developing a care plan," Freil says.

The case manager assesses the members' educational needs and makes sure they have information about their condition. They refer pregnant teenagers to agencies within their community that can provide them with help throughout the pregnancy.

Once the assessment is completed, the case manager stratifies the members according to their needs. The case managers get back in touch with the members according to their stratification and other needs.

The program is telephonic but case managers have the option to call on a home health agency for a face-to-face visit if it is necessary.

"The medical home concept is one of the biggest drivers for us," Freil, says.

Breaking the habit

Members in the Medicaid population tend to use the emergency department for primary care, a habit that CareSource wants to break.

"Once members come into our plan, we encourage them to pick a primary care physician and go for a visit as soon as possible. Our focus is to help these members find a medical home and get preventive health care. We want to educate them, that they don't have to sit in the emergency room for six or seven hours for a non-emergent condition," she says.

The case managers promote well child visits and talk to parents about getting regular check-ups and tests such as mammograms.

"We have a holistic care management program. Instead of separating case management, behavioral health, and social services, we offer family-oriented care management by a team that works closely together to coordinate care," she says.

The health plan contacts the members within 90 days of their enrollment to assess for case management needs. Based on their needs, some members are placed in case management for a short period of time. The majority of members receive case management for a year or longer.

"Some of the members have ongoing medical, behavioral health, and social needs and require interventions over the long run," Lowe says.

The health plan regularly reviews claims data to identify members, Freil says. "If claims data indicate that a member who no longer is in case management may need assistance, we contact them again and get them back into the program," she adds. For instance, if a member makes a visit to the emergency department or is hospitalized, the case manager gets back in touch with the member.

"We want to identify those members who are likely to have the highest utilization and provide appropriate case management," she says.

The health plan launched a new, similar product line in January for aged, blind, and disabled members who have comorbid conditions and complex needs. "Many of these members are aged. The majority have three or four comorbid conditions and take five to seven medications a day. About 60% have complex behavioral conditions as well as medical conditions and social and economic needs," says Kimberly Byrwa, RN, BA, CPHQ, director of case and disease management.

The case managers help the members locate resources within the community that can help with their housing, transportation, and other needs, Byrwa says.

"The case managers help the members identify opportunities to improve their health. They help them understand their pharmacy benefits and become compliant with medication. At the same time, they communicate with the treating physicians, forwarding the information we have gathered and the care plan we have developed for the member in terms of education and resources," she says.