Initiatives target publicly insured young people
Initiatives target publicly insured young people
Case management programs begin with pregnancy
A series of case management initiatives to improve the health of their publicly insured young populations has paid off for Horizon/ Mercy.
On the heels of its successful program to provide better prenatal care for its pregnant Medicaid recipients, the Trenton, NJ-based insurer initiated programs to increase immunizations among toddlers, lower the blood lead levels in youngsters, and educate sickle cell patients. Here are some of the results:
- In the first year of the insurer’s Moms GEMS (Getting Early Maternity Services) prenatal program, only 5% of members in the program had premature babies compared to 13% of the non-GEMS population. The GEMS program babies spent a total of 394 days in the neonatal intensive care program compared to 529 total for the babies of mothers not in the program.
- In the first year of the Children’s Health Assessment, Maintenance, and Preventative Services (CHAMPS) program, which offers support and education to mothers of children from newborn to age 2, the HEDIS figures for well-child visits and immunizations increased by 17%.
- Following just six months of intensive case management for members with high levels of lead in their blood, the average level of the group tracked dropped from 20 to 16.
Horizon/Mercy covers 278,718 members, representing 42% of the state’s total managed care market for the publicly insured.
The health plan’s vision is to help its members learn to navigate the health care system and access the care they need, says Pamela Persichilli, RNC, director of clinical operations for Horizon/Mercy.
The members have access to an extensive network of pediatricians, primary care physicians, and nurse practitioners.
Part of the educational process is teaching the mothers that, under the Horizon/Mercy plan, they have access to a pediatrician office and don’t have to use the emergency room when the child is sick, that they can see a specialist before their sickle cell disease gets so severe they are hospitalized, and that they don’t have to wait for hours at a clinic for shots.
"We have the responsibility to teach them how to access care through their managed care organization. Once you educate someone on how to navigate the health care system, it’s amazing how much happier they are knowing that they can make an appointment and go when it’s convenient for them and not have to wait four hours in a clinic," Persichilli says.
The health plan regularly sends out flyers in various communities, inviting its members to "baby showers" held at a local hospital. The occasions give the members a chance to meet their case managers in person and provide them with information about all of Horizon/Mercy’s programs for mothers and their children.
Case managers face a number of challenges
in dealing with the Medicare population. They frequently encounter disconnected telephones, address changes, wrong addresses, and members who change health plans frequently.
"In the CHAMPS program, we typically reach about 30% of our membership every month. This is about an industry standard with the publicly insured," says Giavanna Ernandes, RN, MSN, APNC, team leader for disease management. She is in charge of the provider’s CHAMPS program, the lead level monitoring department, and the sickle cell disease, diabetes, and congestive heart failure programs.
Under New Jersey law, Medicaid managed care members can change plans every month, and many of them choose to do so.
"That is our single most frustrating issue. If they don’t fill out the paperwork or decide to try another plan, we lose track of what immunizations the baby has had," Ernandes says.
The case managers don’t give up with just one telephone call. They make an effort to keep up with the members.
When the case managers receive information that a member has disenrolled, they call the member and make sure he or she is in another plan.
Horizon/Mercy’s social workers assist in coming up with creative ways of finding members whose telephone numbers and addresses are wrong. They call the pharmacy to see if the members have had prescriptions filled, call the primary care physician to see if they have a different address, and check state Medicaid rolls for a better address.
"We send them as many as three letters asking them to call us back so we can keep up with their child’s health. We try several avenues before we close a case," Ernandes says.
A series of case management initiatives to improve the health of their publicly insured young populations has paid off for Horizon/ Mercy.Subscribe Now for Access
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