Washington Medicaid's care management makes important changes
Washington Medicaid's care management makes important changes
Shirley Munkberg, acting office chief in the Office of Quality and Care Management of Washington's Health and Recovery Services Administration, acknowledges that "it takes care management programs a while to mature and show cost savings." However, when two of the state's recently implemented care management programs were evaluated, a statistically significant decrease in mortality was found.
The programs were similar but with slightly different populations: A chronic care management program done in the Kings County area, and an intensive case management program run through a sister agency working with individuals who receive in-home services.
Based on the findings, some changes were made in early 2009 for the Kings County program, with cost savings to be evaluated again at the two-year mark, at the end of 2010. A cost analysis will be done this year for the intensive case management program.
"We are trying to remeasure to see if we are going in the right direction," says Ms. Munkberg. "One thing we found is that we can't be cost-effective if you can't get contact with people to work with them. If you can't reach people or find them, you can't make any impact on them."
Both programs involve the aged, blind, and disabled (ABD) group, a population with chronic illness and a high utilization of health care, who frequently have unnecessary ED visits and duplicative medication lists. These individuals were very frequently not contacted because they were unreachable.
"So, we did a very concerted effort to find people, working with a research agency that does surveys. This has been very successful," says Ms. Munkberg. "Our previous engagement rate was about 18%, and we are now up to about 40%. It isn't where we would love to be but it's more than doubled."
Another change involved a new emphasis on the patient's own readiness to make changes. "The case managers are practicing motivational interviewing and are using a tool to measure this," says Ms. Munkberg. "They will remeasure it over time, to see if the person has become more activated in their own care. They are using the level of the person's activation to help them set goals."
Another lesson was that a "face-to-face" model was needed, as opposed to contacting clients by telephone. Trying to reach the clients by phone wasn't working for many reasons. Some individuals didn't have phones, while others had only a limited number of minutes on a cell phone, weren't willing to talk to the state, or moved from place to place staying with relatives or friends.
Also, while the length of time for case management previously was limited to six months, it was determined that with this population, it takes almost that long just to build a relationship. "So, we have taken that time limit off. The case managers are able to work with the client as long as they need to," says Ms. Munkberg. "We will be measuring that in our evaluation at the end of 2010."
Here are several care management programs implemented by Washington Medicaid:
A frequent ED users program.
Nursing case managers are able to use the client profile information in the Medicaid application to see medication utilization and refill patterns, preventive health care gaps, primary care, and specialty care utilization. "This information is helpful in identifying health care goals the client can strive for in self-management of their conditions," says Ms. Munkberg.
The Washington Disease Management Program
In 2002, Washington became one of the first states to implement a disease management pilot program for Medicaid beneficiaries. The program, which operated on a statewide basis until 2006, was open to fee-for-service ABD beneficiaries with targeted chronic conditions. Children with asthma also were eligible to participate. Two vendors provide disease management services for approximately 20,000 eligible beneficiaries with any of eight targeted conditions.
"By improving care coordination for these target populations, the program set an overall goal to decrease medical expenditures by 5%," says Ms. Munkberg.
The program succeeded in raising the quality of services available to some chronic care patients, and reduced hospital days for children with asthma and beneficiaries with end-stage renal disease. However, it did not generate the cost savings specified in the contract.
"The state believes that cost savings may have been hindered for two reasons," says Ms. Munkberg. The population may have been less stable, in terms of eligibility for services, than assumed. Secondly, participating beneficiaries were encouraged to use preventive care for their chronic conditions. This may have driven up the use of provider services in the short term.
"Furthermore, and perhaps most importantly, the state recognized that given the complexity of its Medicaid population and the predominance of multiple chronic conditions, the single-diagnosis model did not necessarily reach the state's highest-risk populations," says Ms. Munkberg.
The Washington Medicaid Integration Partnership
Since Washington's Disease Management program focused only on beneficiaries with single chronic conditions, the state wanted a more comprehensive approach to address the disproportionate use of services by ABD beneficiaries.
The state contracted with Molina Healthcare of Washington to run the Washington Medicaid Integration Partnership, launched in January 2005. The program was designed based on the premise that increased access to and better coordination of mental health, chemical dependency treatment, and long-term care services would lower medical costs and reduce mortality.
"This program serves approximately 3,000 beneficiaries and has demonstrated positive initial results for key measures," says Ms. Munkberg. Inpatient admissions and days in state mental hospital facilities have decreased compared to fee-for-service beneficiaries. Patient satisfaction with aspects of care delivery, such as shorter wait times for routine care appointments, also has improved.
The Medicare-Medicaid Integration Project (MMIP)
This program was launched in 2005, to integrate medical and long-term care and financing for dual- eligible seniors in two counties. Dual-eligible seniors in King and Pierce counties could voluntarily enroll in both a Medicaid-contracted state plan and a Medicare Advantage Special Needs Plan.
"The program got off the ground slowly for a variety of reasons," says Ms. Munkberg. "The timing paralleled the launch and promotional muscle of Medicare Part D. This made it difficult to deliver clear messages about the benefits of MMIP." The state set a goal of 500 enrollees by the end of 2007, but only 225 dual-eligibles were enrolled in the program at year-end.
"Beneficiaries participating in MMIP gave it positive reviews," says Ms. Munkberg. "But because of the small enrollment numbers, the decision was made to disband the program in early 2008."
Chronic Care Management Program (CCMP)
In 2006, the state sought a new strategy to progress from a disease-specific focus to a more holistic approach for its most complex and costly populations.
"In particular, state officials felt it was critical to target beneficiaries who would benefit most from care management techniques, to prevent the disease progression that results in increasingly expensive care and poor quality of life," says Ms. Munkberg.
As a result, the state developed the CCMP. This program, launched in January 2007, pairs the techniques refined in the state's Disease Management program with a predictive modeling tool that identifies beneficiaries at highest risk for service use.
CCMP provides case management, education, and support, as well as assistance accessing health resources, for fee-for-service ABD beneficiaries who are identified as high risk.
The state contracts with two vendors for CCMP. The King County Care Partners (KCCP) project is a local care management program that provides medical home and care management services to enrolled beneficiaries in a limited geographic area. United Healthcare Services/AmeriChoice is a statewide vendor responsible for the predictive modeling tool that is used to identify potential beneficiaries for its program and for KCCP.
"This vendor also provides more traditional telephonic disease management and care management services," says Ms. Munkberg. "This two-pronged approach allows the state to test different models of care to see what works best and continuously improve program quality."
Both contractors are expected to provide the following care management activities for participating beneficiaries:
Screen/assess risk factors such as health status, self-management skills, adherence to treatment plan and prescribed medications, and individual needs such as limited English proficiency and health literacy.
Develop a personalized care plan that includes a focus on self-management skills.
Link beneficiaries to a medical home.
Refer beneficiaries to medical, mental health, chemical dependency service providers, and other social services as needed.
Contact Ms. Munkberg at (360) 725-1648 or [email protected].
Shirley Munkberg, acting office chief in the Office of Quality and Care Management of Washington's Health and Recovery Services Administration, acknowledges that "it takes care management programs a while to mature and show cost savings." However, when two of the state's recently implemented care management programs were evaluated, a statistically significant decrease in mortality was found.Subscribe Now for Access
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