With a field-based care management program, WellCare Health Plans has reduced hospitalizations, ED use, and readmissions. The program also has improved prescription use and outpatient services.
- The program identifies a high-risk Medicare/Medicaid population through claims data and clinical information.
- Care managers use an engagement script to encourage plan members to join the program.
- Aided by field visits, care managers complete a comprehensive assessment and an environmental assessment.
WellCare Health Plans in Tampa, FL, implemented a field-based care management program with the goal of changing an industrywide reactive model into an innovative, proactive model that is used with a high-risk Medicare/Medicaid population.
The first aspect of the model is proactive identification of people who need in-person case management. “We are not waiting for a crisis to happen before we seek to engage our membership,” says Michael Radu, senior vice president of clinical operations and business development for WellCare Health Plans, which covers 15 states for Medicare and nine states for Medicaid.
“We focus on the most vulnerable people and use a variety of information that’s available to us, whether it’s claims data or clinical information,” Radu says. “We focus on individuals with chronic conditions that are actionable, and we have an eye toward people with multiple chronic conditions.”
The care managers, who have nursing or social work backgrounds, meet at people’s homes and assess each individual, starting with the person’s goals and social determinants of health. The care managers then develop a care plan that will be seen by a comprehensive and integrated care team, he says.
This approach has a broad spectrum of results, including reducing hospitalizations, ED use, and readmissions, Radu says.
“What was pleasing to us is we saw services increase in a couple of areas where we felt it validated our outcomes,” he says. “Our prescription use went up 3%, which we thought was a good indication of better medication adherence. We saw outpatient services go up, which we felt was better access to care in the right setting.”
The following is how the program works:
• Launched with engagement script. “When we launched the program in four markets, we sort of left it to each program to develop their engagement script, and we had a wide variation in reach and engagement,” Radu says.
The program is being expanded and relaunched with a standardized script that care coordinators learn through role playing, he says.
The type of language people use is important, and care coordinators are trained in how to describe the program to plan members, such as emphasizing that the program is a free benefit to the member, he adds.
Among the lessons learned are strategies for making initial telephone contact and finding times and telephone numbers for reaching people, he says.
• Market the program to plan members. Another strategy for enrolling people in the program involves four- or five-minute videos available on YouTube, in which a patient and his or her care management team talk about how the program can help people.
In one such video, a social work care manager talks about how she rode on the bus with an amputee WellCare member to the doctor’s office. “I would go with her on the bus to make sure she made it safe and sound,” the care manager said. “I want to make sure every part is addressed; not just the medical part, but the social needs because I know that is a major factor.”
• Provide comprehensive assessment. “We have general guidelines tailored to individual situations for the member,” Radu says. “The first contact after setting up the logistics is a comprehensive assessment on the first visit that could take an hour to two hours.”
The assessment’s intensity depends on the individual’s chronic condition, activity level, social support, and needs, he says.
• Do an environmental assessment. The power of having a face-to-face visit is that the care manager can assess the plan member’s nutritional status by checking the refrigerator and cabinets. Also, the case manager can look at pest control issues and safety factors involving rugs and whether the person needs grab bars or other environmental assistance, Radu says.
Case managers can look at the person’s medications and do an inventory of his or her prescriptions. If problems are identified, the care manager can request that a pharmacist conduct a medication reconciliation, he says.
• Engage with communities. “We have a formal program of surveying hundreds of thousands of community and program providers,” Radu says. “We employ community outreach workers who go out into our states in person to develop relationships with a lot of the community providers.”
On rare occasions, the organization can formalize its relationship with community providers and share confidential member information to ensure people have access to those community resources, Radu says.
Most of the time the community organizations can be resources for when members have food insecurity issues or need financial support, rent assistance, or help with utilities. These organizations also can help with transportation and dental and vision care, he says.