Blended care management model cuts costs for high-risk Medicaid members

Health plan takes holistic approach to meeting patient needs

A blended model of care management has decreased hospitalizations and emergency department visits and cut medical expenses for high-risk Medicaid recipients with Keystone Mercy Health Plan.

"Since we began this program in 2004, we have had the results analyzed by three outside entities as well as looking at them internally. All have shown a definite cost savings," says Karen Michaels, RN, MSN, MBA, vice president of clinical services for the Philadelphia-based health plan, which is a member of the AmeriHealth Mercy Family of Companies.

The blended model encompasses care management, health interventions, member-centric care plans, and a coordinated outreach approach and is tailored to help meet the challenges in providing services to Medicaid beneficiaries, Michael says.

Medicaid members have so many challenges in their lives that taking care of medical conditions and working on improving their health may not be a high priority. Instead, they are more focused on issues such as how to get the rent paid or getting the electricity turned back on, and often have little energy or time to devote to handling their medical issues, she adds.

"One of the main challenges with the Medicaid population is that this membership is very fluid. They aren't in one location for a long period of time; their contact information changes often. Just locating them and staying in touch is a challenge," Michaels says.

The program blends the areas of disease management and case management into a care management program, says Lynne Harsha, assistant vice president for PerforMED operations at the health plan.

"We have combined specific elements of our chronic condition management program and care coordination capabilities with our member advocacy approach to create a unique, intensive care management program. When we contact the members, we don't just talk about their diabetes or heart failure. We discuss what else is going on in their lives and focus on addressing the most urgent health-related issues while also considering what the members consider to be their most immediate concern," she says.

The program isn't limited to helping members manage their physical health, Harsha adds.

"The blended model also includes a behavioral health component that connects the members to the resources and care they need to manage their overall health in a holistic, member-centric fashion," she says.

The health plan's high-risk Medicaid members have a high instance of behavioral health issues, including depression and bipolar disorder, Michaels adds.

"A lot of medical management models include just disease management based on an illness or just case management or a stand-alone program for smoking or weight loss. Our blended model integrates all of those services, and our rapid response and outreach team ensures that there are no fragmented points of contact," Michaels says.

Rapid response and outreach team staff handle inbound calls from providers, community agencies, and members and work with those members who need help on a short-term basis.

"In our unique model, the member services department refers members to the rapid response unit for help with issues around health or social support even if they aren't necessarily a candidate for long-term case management or disease management or our blended model," Harsha says.

For instance, a member may have a broken wheelchair and need to get it repaired. Someone else may have lost his or her prescription and need support in calling a physician for a new copy.

The rapid response and outreach team helps members with their immediate problems and follows them to make sure they are stabilized before they close the case. They leverage their knowledge of community-based programs and help members connect with other resources.

"They work with all of the departments at Keystone Mercy and understand what services are provided and how to advocate for the members to deal with any kind of issue," Harsha says.

The majority of members in the high-risk program are identified through an analysis of claims and pharmacy data using an algorithm that predicts future health care utilization as well as severity of chronic illness.

Members who are the sickest or most likely to have future health care needs are targeted for the program.

The plan also receives referrals from physicians as well as self-referrals from members.

Other members eligible for the program are identified by a health risk assessment given to all new members by the utilization management staff, which handles authorization for services and medical necessity and refers cases when they identify a situation that needs care management.

Once members are identified as eligible for the high-risk program, the health plan tries to reach them by telephone. If their number has changed, the team contacts the physician or pharmacist to get a correct phone number.

In some markets, the health plan sends its community outreach solutions "street team" to the home to make contact with the member.

The "street team" staff are lay people who are trained and equipped to conduct outreach. Many of them are hired through the Welfare-to-Work program and come from the same community as the members. Others may be Medicaid recipients themselves.

The program takes a team approach to coordination of care. The team includes the care manager, either an RN or a social worker depending on the needs of the member, a case management technician, the member's primary care physician, the member, and his or her family members.

Most of the case management technicians have a medical background and customer service experience. They are trained in medical terminology, customer service, patient advocacy, and resources in the community and assist the care manager in helping members access services such as food banks, pharmacy assistance, and transportation.

"The care manager and the case management technician work as a team. This arrangement maximizes the time for the care managers, allowing them to focus on matters that need their clinical expertise," Harsha says.

Once the care manager connects with the members, he or she starts the assessment process. The care managers have access to screens that show claims data, physician and emergency department visits, prescriptions, and hospitalizations.

"They find out what the members know about their medical conditions and medications and compare it with what we have in our system. They ask about their living situation and screen for depression," Michael says.

The care managers begin by establishing a relationship with members, identifying their priorities and finding goals that are meaningful to them. For instance, when a member has heart failure and needs to maintain his or her fluid balance and lose weight, the care manager won't focus on weight loss but might work with the member to establish a goal of being able to walk around the mall with her children.

"As we collect that information, we start to generate a care plan. We identify potential areas we want to work on and set goals for the benefit of the member, and not just their health status," she says.

The care managers contact the members' primary care physician and collect information from the office as well as finding out any gaps in information that the physician may need.

The care manager sends a summary of the care plan to the member and to the physician.

The health plan's electronic system automatically creates tasks in the care plan for each of the team members.

For instance, the care manager may ask the case management technician to arrange an appointment with a physician or set up transportation for a test or procedure.

Once the care plan has been established, the case manager sets up the tasks and follows up with the member, providing education, general support, and education.

"The care plan is an ever-changing one. Sometimes, down the road, members have other needs, such as experiencing fluid retention, problems ambulating, or needing food; we continuously re-evaluate the members' priorities and ensure that they have the resources they need," she says.

The care managers work on each member's individual issues, help the members work through the barriers to adherence, and keep them focused on steps they can take to improve their health, Michaels says.

In the beginning, the care manager may contact the member every day and gradually taper off as the member's needs stabilize.

"Our goal is to get enough assistance to support the member's ability to self-manage his or her conditions. As the member becomes more independent, the care manager decreases frequency of contact to every one to three months, checking on follow-up appointments and making sure the member's needs are being met," she says.

Some members get to the point where they don't need assistance and the case manager closes the case, Harsha says.

"We have a large group of members in this program, such as those with heart failure and diabetes, whose needs will be ongoing. We keep these cases open indefinitely," she adds.

The vast majority of contacts between the member and the case manager are by telephone.

"On occasion, a case manager will meet a member who needs special consideration in the home or a provider office," Harsha says.

Members are assigned a nurse or social worker care manager depending on their needs. The social work care managers work with members who have intense behavioral health issues and fewer medical issues.

"The two disciplines have rounds where they talk about cases that are challenging. They consult each other frequently and work as a team," she says.

Some of the staff work from home but are in touch by telephone and e-mail.

The health plan holds care management rounds every two weeks. During the rounds, staff members present challenging cases and the team brainstorms strategies and solutions.

"It's an open and sharing session. We take turns presenting cases, and the team shares their experiences with similar cases and strategies that have worked. The whole staff learn from this approach," Harsha says.