CMs increase primary care visits for SSI members

Challenging population needs personal contact

Tarrytown, NY-based Hudson Health Plan's case management program, aimed at members with chronic diseases or disabilities, has increased the number of members in the program who see a primary care physician or a dentist.

The program is aimed at members who are 18 or older and eligible for Social Security income. To qualify, they must not have visited a primary care physician in more than a year or seen a dentist in two years.

"Regular primary care and dental care are important, especially for patients with chronic diseases and disabilities. We decided to go back to basics and see if the people with chronic illnesses were getting primary care physician and dental visits. We pulled a subset and looked at a 600-member pilot group to see their utilization," says Margaret Leonard, MS, RN, C, FPN, CM, vice president of clinical services.

During the pilot project, which began in 1999, the number of members in the program who saw a primary care physician for regular visits increased to 77% from 62%, and those who saw a dentist to 42% from 53%.

After the pilot project proved successful, the program was rolled out to all members receiving Supplemental Social Security (SSI) benefits.

The goal of the project is for 80% of members with chronic diseases and disabilities to receive regular primary care physician visits.

The SSI population is a challenge for case managers, especially in the managed care world, Leonard says.

Almost half of the members in the program have chronic disabilities or diagnoses related to mental health.

"When people are disabled, whether they're mentally ill or have a disabling physical condition, their illness becomes their major driving force. It's what they concentrate on instead of having their teeth taken care of or getting a mammogram or taking their children for their shots," Leonard says.

Before beginning the initiative, the health plan developed an information system to track primary care physician and dental visits of members based on CPT and ICD-9 codes. The next step was a barrier study to determine why members were not going for primary care and dental care.

The study showed that lack of knowledge about their benefits was not what was keeping members away from getting care.

"For the most part, they knew about their benefits. They didn't see the urgency of seeing a dentist, and most didn't believe they needed to see a primary care physician because they were already seeing a specialist," Leonard says.

To encourage members to go for preventive care, the health plan offers them an incentive, in the form of a prepaid telephone card, if they see the primary care physician and the dentist.

Providers receive a $50 bonus incentive if they complete a medical evaluation form that includes contact information for the member. The bonus encourages the providers to share information with the health plan about primary care and dental visits.

Many of the members in the SSI program have mental health problems, difficulties communicating, or language barriers, making it difficult for the health plan's customer care representatives to communicate with them.

Hudson's solution was to create a new position, bilingual case management assistants who have excellent communication skills and go through an intensive training program that teaches them how to work with the disabled population.

The SSI population is sicker than most publicly funded members and tends to be more homebound with working telephones, in contrast to nondisabled, publicly funded members who are transient and may not have a telephone.

They need to be contacted by someone who is sensitive to the fact that they may come across as hostile because of their mental health status, and someone who is trained to deal with the barriers in communication, Leonard says.

When a member is identified for the program, the case management assistant makes the initial call, explains the health plan's benefits, and talks to the members about the importance of making regular visits to the primary care physician and primary care dentist.

During the orientation phone call, the case management assistant explains how to use the insurance card and how to access providers in the network. She finds out if the member knows who his or her primary care provider is and gives him or her the number if they do not. She reinforces what health care services are available and what providers the member should see on a regular basis.

She gets information on the member's medications and other clinical data and passes it on to the RN case manager, who will follow up and work with the member on a regular basis.

Each member gets a handbook containing information about the plan and the benefits it provides, along with guidelines for what examinations and care they should be receiving.

If the case management assistants don't reach the members after three phone calls, Hudson Health plan sends them a postcard, followed by a letter, asking them to get in touch.

The case manager calls the member, reviews what data already are in the system, and gets additional data. The case manager completes a disability assessment and enters the score and other information into a computer system that Hudson Health Plan developed in-house, which stratifies the member into a level of care.

The tool identifies the kinds of help the members need with activities of daily living, dictates the need for further interventions, and creates a tickler to remind the case manager it's time to get in touch.

Some members feel that they don't need to go to the primary care physician if they are seeing a specialist. They say they don't have time to see a doctor or their primary care physician is in an inconvenient location. Barriers to dental care include fear of the dentist or the belief that they don't need to go because they have dentures.

As the member brings up each excuse, the nurse case manager addresses them. The case manager can arrange for transportation service, help make an appointment, and deal with whatever issues arise.