Partnerships help plan reach at-risk Medicaid members

Community-based providers work with plan's CMs

By partnering with community-based providers throughout the state, Optima Health of Virginia Beach, VA, provides one-on-one intensive case management to high-risk members in its Medicaid disease management programs. Optima Health is a service of Sentara Healthcare.

The health plan provides a telephonic disease management program for the majority of members and supplements the program with one-on-one visits for people who are most at risk, working hand-in-glove with community agencies to meet all the needs of its members.

"We have always felt that for high-risk members, those with the most demands on health care and the least resources, we should come up with something different," says Karen Bray, PhD(c), RN, CDE, disease management program director.

To address the challenge of locating members at risk and engaging them in case management programs, Optima Health contracts with local community-based providers across the state who are known to the at-risk Medicaid patients. They include agencies that employ members of communities with high Medicaid populations and local home care agencies that have staff whom everyone in the community knows.

"These agencies may have laypeople who can go out into the community and help us locate Medicaid members. Since they live in the community, the members we want to reach are more likely to respond to them," Bray explains.

When the contracted staff locate the members who have been targeted for Optima's disease management programs, they educate them about what the health plan is trying to do.

"We identify what the member needs and find those resources that are available in their community," Bray says.

The health plan has a generic telephonic disease management component and a LifeCoach component in each of its disease management programs.

LifeCoach programs, available for the high-risk population, mean different things depending on the member's specific clinical problems.

For instance, Optima's Partners in Pregnancy program aims to promote healthy pregnancies and reduce premature births. A nurse case manager contacts the members who are at high risk for pregnancy complications and follows them throughout their pregnancy.

Optima also partners with Virginia's Comprehensive Health Investment Project (CHIP), which provides support to at-risk families throughout the state. CHIP sends out a team of lay workers and nurses on a regular basis to help coordinate the care of pregnant women who are at high risk for complications.

They tackle psychosocial problems such as abusive households and families that don't have enough food and whose utilities are about to be cut off, and help them connect with social services agencies that can provide assistance.

"The Partners in Pregnancy Program does what it takes, within reason, to ensure that the baby is full-term. It may help get the at-risk pregnant woman off her feet by looking for resources to do cooking, cleaning, and help care for her children, if appropriate," Bray says.

The Optima case managers hold case conferences with the CHIP workers to keep up to date with what is going on with the members, she says.

Optima estimates that the community-based pregnancy programs have helped avoid nearly 3,000 days in the neonatal intensive care unit since 2002 and that for every dollar spent on the program, the plan saved $2.80.

Members in Optima Health's asthma program receive at least one phone call from an RN, respiratory therapist, or case manager and a packet of information on recommended asthma care.

For at-risk members, Optima Health contracts with home care agencies that already are sending nurses or respiratory therapists into the homes in the low-income neighborhoods.

The nurses or respiratory therapists serve as LifeCoaches, visiting high-risk members and conducting a complete environmental assessment of the home to determine the triggers that exacerbate the member's asthma.

"They look at the general living environment. For instance, if the family has a pet, they may suggest keeping the animal out of the sleeping quarters or talk to the member about how to reduce the amount of pet dander in the environment," Bray says.

Among 451 members continuously enrolled over a five-year period, the health plan saved $1.09 for every dollar in program costs.

The diabetes program sends Optima Health nurses who are diabetes educators to the offices of the community physicians with a high number of patients with diabetes.

The nurses spend half a day each week in each physician's office, meeting with all interested patients covered by Optima Health and educating them on appropriate care, blood glucose monitoring, the importance of taking their medication, and self-management skills.

They work with the physicians to develop a treatment plan that follows best practice guidelines and work with the patients to develop goals.

"It gives the physician a resource they wouldn't otherwise have and gives the members someone who can help them communicate with their doctor," Bray says.

The nurse educators work in six large physician practices. The health plan advises its members as to when the educators will be in their physician's office and encourages them to set an appointment on that day.

Members who meet with the Optima LifeCoach in physician offices have been statistically more adherent with medication regimes and enjoy better control of their disease, Bray says.

Members who do not live in areas where there are a lot of Optima members with diabetes receive standard telephone management.

"Through this program, the nurses understand the practice patterns of the physician, and the physician realizes the benefit of having a nurse to work with his patient. The physician and nurse work together for the benefit of the patients," Bray says.

The 1,000-plus patients participating in the Diabetes LifeCoach program showed a 21% improvement in achieving an A1C level of less than 7%; a 22% improvement in achieving a blood pressure level below 130/80, and a 13% improvement in achieving a low-density lipoprotein (LDL) level less than 100 when compared to the baseline year.

The patients showed similar gains in receiving recommended screening and testing, appropriate medication utilization, and preventive care activities such as foot exams, nutritional counseling, and smoking cessation counseling.