Medicaid patients may need extra help to obtain their care

Social needs, family problems take precedence

Managing the care of Medicaid members and ensuring that they obtain the services they need is always a challenge, case managers report.

Many Medicaid beneficiaries don't understand the healthcare system. They might suspect that "case manager" means a government worker who might take their children away and refuse to return phone calls. Several beneficiaries move around from location to location and often change their pre-paid cell phones, which makes them difficult to locate.

When case managers do find them, they often are more worried about whether they're going to be evicted from their home or how they're going to provide food for their family, and don't think about weighing themselves or checking their blood sugar level daily. (For more information about establishing a presence, see story, below)

"Everybody struggles with making sure that people have enough knowledge and enough resources to stay reasonably well. It is important for case managers, providers, and other healthcare professionals to remember that this is a very vulnerable population and to be as accommodating and welcoming as possible," says Dana Pepper, RN, MPA, manager of strategic planning and business development at Mercy Care Plan, Phoenix, AZ, and former executive director at St. Elizabeth Health Center in Tucson, AZ. "It takes a variety of strategies and a lot of work to make sure low-income people receive healthcare services. This is not a one-size-fits-all problem."

Because Medicaid has low or no co-pays, Medicaid patients don't have the financial barriers in terms of paying for healthcare services, but they do face other barriers to taking care of their health. The Medicaid population often faces challenges with navigating through the complexities of the healthcare system, says Carol Perniciaro, RN, BSM, manager of care and disease management for Horizon NJ Health, a West Trenton, NJ, Medicaid health plan. In addition, most have poor healthcare literacy which can create huge barriers to adherence. (For tips on how to reach and engage members, see related article, below.)

Case managers should go to great lengths to ensure that Medicaid members understand what they need to do to follow their treatment plan, says Lisa Clark, RN, BSN, CCM, supervisor of care management for Horizon NJ Health. "Our case managers use the teach-back method to make sure they understand," Clark says. In some cases, the case managers go so far as to ask the members to walk them through the steps they are going to take to get their prescriptions filled, including where they're going to go and how they are going to get there. In addition, Horizon NJ Health has simplified all of its materials, programs, and newsletters to better promote understanding among all members, she adds. (To learn other ways to engage members, see related article, below.)

Many times, making regular visits to see a primary care doctor has a low priority for Medicaid beneficiaries, says Donna Zazworsky, RN, MS, CCM, FAAN, vice president at community health and continuum care, for the Tucson-based Carondelet Health Network. They might be hourly workers or have jobs as day laborers and work whenever they can, and they might skip their doctors' appointments if they are offered jobs. Or they might make appointments but have family issues that come up, so they can't keep the appointments. Case managers can help by assisting patients in finding providers who have extended office hours and by steering patients who care for young children to providers who offer child care, she adds. For instance, St. Elizabeth Health Center has a childcare center where children can play while their parents are seeing a provider, she adds.

When you work with Medicaid beneficiaries and other low-income patients, expect a lot of no-shows and cancelled appointments, Zazworsky says. "Providers should expect a higher no-show rate because of all the barriers these people face, and schedule accordingly. At St. Elizabeth Health Center, the staff contacts patients who miss an appointment to check to make sure they are OK and to try to reschedule," she says.

Pepper points out that transportation is a major roadblock that Medicaid recipients and other low-income patients face when they seek healthcare. Many Medicaid plans offer transportation, but it's still difficult for people to get to appointments. Zazworsky adds, "Case managers should make sure the providers are at a convenient location for the patients and that the offices are on the bus line or otherwise easily accessible."

Recognizing the cultural beliefs and practices of your Medicaid patients is also important, Zazworsky adds. "It takes a long time to understand what is comfortable for the immigrant population," she adds. For example, women in some cultures want to see only women providers. Some want to meet their provider on the first visit and be examined the next time.

CM starts with telephone contact

Reaching members is a challenge

Sometimes just reaching a Medicaid member can be a challenge, Lisa Clark, RN, BSN, CCM, supervisor of care management for Horizon NJ Health.

"Our members tend to move frequently and often change cell phone numbers," she says. The health plan collaborates with the primary care physician offices in their network and community agencies for help in locating members.

Sherry Rumbaugh, RN, director of care coordination for Passport Health, a Medicaid health plan with headquarters in Louisville, KY, reports that when Passport Health case managers are unsuccessful in contacting members, they review the member history and contact the pharmacy and/or healthcare providers the member has used for updated contact information.

Recognizing that many of the members are the working poor, Horizon NJ Health makes outreach calls during the evening hours to reach members who have gaps in care. Clark says: "Often we call someone with a specific gap in care in mind, but we don't get to it because the member has more pressing issues to talk about."

Passport Health is expediting help for its Medicaid members who have basic needs such as housing and food. It has created the Rapid Response line, a toll-free number that members can call when they need help in accessing resources, such as transportation and housing assistance, and when they have medical questions. Rumbaugh says, "The Rapid Response Team is trained to link members who call to whatever resources they need, whether it's clinical or non-clinical. In addition to questions about their benefits and health questions, people call us for help when their electricity is about to be cut off or they can't pay their rent."

The rapport that the Rapid Response Team builds with members is an asset when the health plan's case managers or disease managers try to engage members in following a treatment plan. "Sometimes case managers will call to engage a member in disease management, and they are perceived as someone who is not going to be helpful. Because they have built a rapport with members, the Rapid Response Team can convince them that the case manager is here to help," Rumbaugh says.

Face-to-face visits create a bond

Encounters build trust, respect

Health plans need to reach out to Medicaid members to engage them and educate them about the services they provide, says Dana Pepper, RN, MPA, manager of strategic planning and business development at Mercy Care Plan, Phoenix, AZ, and former executive director at St. Elizabeth's Health Center in Tucson, AZ.

"A major issue is making sure that all the people who are eligible for service are enrolled in a Medicaid plan," Pepper says. "People who are eligible for Medicaid may not know it and even if they do, they often have difficulty in following through with the enrollment process."

Donna Zazworsky, RN, MS, CCM, FAAN, vice president for community health and continuum care, for the Tucson-based Carondelet Health Network adds: "To reach patients who are eligible for Medicaid, organizations need to station outreach people in multiple access points to guide people eligible for Medicaid through the enrollment process and make sure the paperwork is done properly." At St. Elizabeth's Health Center, and other hospitals and clinics in Tucson, when people come in for treatment, the staff make sure they have enrolled in any assistance programs for which they are eligible, and helps them overcome the barriers to enrollment.

Once people are enrolled in Medicaid, it might take a while for case managers or other health plan representatives to build up a relationship with them, says Sherry Rumbaugh, RN, director of care coordination for Passport Health Plan, a Medicaid health plan with headquarters in Louisville, KY. "Sometimes we have to work through the mistrust that members have. When we see them face-to-face, it helps us build rapport and get a better feel for what they need," Rumbaugh says. The health plan has placed nurses and social workers in two high-volume provider offices where they work with patients face-to-face and, over time, build up trust. "We've had really good success in helping members complete health screening, identifying their healthcare needs, and eliminating barriers to care," Rumbaugh says.

When they identify members who frequently use the emergency department for non-emergent care, the Passport case managers ask emergency department staff to alert the health plan if the member shows up for treatment. Then, a social worker visits the members in person and educates them on more appropriate ways to obtain healthcare. For example, one member was going to the emergency department several times a day for minor problems. When the health plan received a call from the hospital, a social worker visited the woman in the emergency department and worked with her. Now, she's gone as long as three months between emergency department visits.

"The emergency department was a social network for this member. When she got lonely and wanted someone to talk to, she'd go to the emergency room. The social worker built up trust with her, and now she calls when she wants to talk," Rumbaugh says.

Establish a presence In the community

Visits can impact Member engagement

Horizon NJ Health, with headquarters in West Trenton, NJ, sends its fleet of mobile medical and health vans, called Care-A-Vans, into communities throughout the state for outreach, health education, enrollment information, and no-cost screenings of members.

The health plan partners with school, community, and faith-based organizations. On average, the Care-A-Vans participate in more than 300 health fairs and other events each year. Some of the programs are multi-lingual, depending on the cultural make-up of the community.

When the Care-A-Vans visit communities, the health plan staff assist in enrolling eligible members, present educational programs, and conduct blood pressure, blood sugar, and other screenings. Carol Perniciaro, RN, BSN, manager of care and disease management for the Medicaid health plan says: "The Care-A-Vans have established our presence in the community and have had an impact on our efforts to engage members. People realize that we are there to help them, and they call us when they have a need."

Sherry Rumbaugh, RN, director of care coordination for Passport Health Plan, a Medicaid health plan with headquarters in Louisville, KY, adds, "The process for engaging members has changed over the years. When I started in case management, we mailed information to members. Now, we're looking at other ways to reach our members."

Passport Health is using text messaging to provide information. For example, the health plan sends regular free texts about nutrition and child care to its pregnant members and those who have recently delivered a baby. "Many of our members have pre-paid cell phones and don't want a lengthy conversation over the phone," Rumbaugh says.

The health plan participates in community events and is working with local churches to get the word out to members about the services the health plan can provide. A Passport staff member presents a short program each week on one of the local television stations and discusses the health plan's health management programs.