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Chronic care project targets most expensive LTC clients
Washington's Chronic Care Management Project targets the most medically expensive, high-risk Medicaid clients in its long-term care system. It has lowered mortality and improved the health of clients with chronic conditions such as diabetes, heart disease, and musculoskeletal diseases.
"We had been designing our program to improve health outcomes, reduce medical costs, and improve self-management skills. So, we were very pleased that it worked," says Candace Goehring, MN, RN, unit manager with the Aging and Disability Services Administration (ADSA)'s Home and Community Programs. "We had not anticipated measuring mortality rate, so that was a surprise finding."
Over a two-year period, nurses were assigned to more than 400 adults. During face-to-face interactions, clients were encouraged to take charge of their own health issues and reduce the need for health care services. Clients were connected to community-based experts and participated in dietary, pain management, and physical activity programs in addition to care management interventions.
Here are some of the approaches that make the program unique:
Predictive modeling data is used to select potential enrollees at highest risk for future health care utilization, based on analysis of demographics, health care claims, and utilization.
"Predictive modeling data was also used to identify care opportunities for client goal setting," says Ms. Goehring. For instance, clients with diabetes who have not had podiatry care, retinal eye exams, or A1C testing, might set a goal to obtain those routine exams to improve their diabetes management.
Likewise, individuals with ED visits related to falls identify approaches to reduce their risk of future injuries. "Clients with treatments for infections, such as urinary tract or respiratory infections, identify strategies to better understand their symptoms, when to call their primary care physician, and prophylactic care," says Ms. Goehring.
Care management with individualized assessment and intervention is provided to high-risk clients by a nurse care manager.
"This results in a plan of care jointly developed by client and care manager," says Ms. Goehring.
Client activation levels are determined using the Insignia Health Patient Activation measure and a "coaching" approach.
Over the course of working with the nurse in a coaching relationship, clients increased their levels of activation, with more confidence in managing their own health conditions.
Intensive care management services are provided through the state.
"These integrate acute and long-term care services, using face-to-face care management focused on supporting existing ADSA clients living in their home," says Ms. Goehring.
The program builds on long-term care casework and in-home service delivery infrastructure through Area Agencies on Aging.
The nurse care managers work for the same organizations that provide the case management for this group of long-term care clients. "In some cases, they had previously worked with these clients to support their long-term care plan," says Ms. Goehring. "This existing relationship aided in engaging clients and bridging the network of long-term care services with the medical care the client was receiving."
Clients remain in the project for the period of time that they are eligible for chronic care management services.
"We were able to allow the client and their caregivers to engage in the health action planning process and work towards lifestyle and behavior changes that require time and effort to accomplish and sustain," says Ms. Goehring. "A client's perception of need and readiness for change will determine the speed of the change."
The engagement rate was 43% of those targeted for the program, similar to other projects nationally. A client survey measured Overall Health Rating, Patient Activation Measure, Overall Self-Sufficiency, Pain Impact, and Quality of Life Scale. For all five areas, the results consistently pointed to better self-reported health outcomes in the treatment group than the comparison group.
"There was a statistically significant lower risk of death among the clients randomly assigned to being offered chronic care management in the 10-month study period," says Ms. Goehring. "Those in the treatment group had lower average medical costs in the first 10 months of the project than those not offered treatment, though this was partially offset by increased in-home long-term care services."
Findings from the client record review showed that nearly half of the clients in the sample achieved improvements in health condition, living environment, or access to treatment. "The greatest challenges appeared to be resource limitations, particularly in rural areas of Washington state," says Ms. Goehring.
More clients in the treatment group reported usually getting an appointment at a doctor's office or clinic as soon as they thought they needed it. Another finding was a high prevalence of mental illness in individuals with high-risk chronic conditions. "Improving health and reducing health-related costs requires intentional and individualized care planning with client-centered goal setting," says Ms. Goehring.
A 22-month cost-and-outcomes evaluation found similar trends as a previous evaluation done at the 10-month mark. "We are looking towards expansion of chronic care management to more eligible clients receiving long-term care services," says Ms. Goehring. In the program's first round of expansion, the number of clients will increase to 1,000. Ultimately, the program could enroll as many as 12,000 people.
Although enrollees in the program were less likely to die in the 22-month follow-up period, the decreased mortality rates that were statistically significant at the 10-month follow-up have moderated over time.
The second evaluation found that enrollees were less likely to have inpatient hospital stays involving ED visits. This resulted in an estimated medical cost savings of $253 per person, per month. Overall, including the $180 per month cost of enrollment in the program, a small net savings of $27 per month was seen.
Despite these encouraging results, client engagement is and will remain a challenge for any program targeting high-need, high-cost Medicaid clients. "Offering services does not guarantee client engagement," says Ms. Goehring. "Ultimately, clients can decide whether their preference is to participate, but many of them at the point of introduction do not understand what they are declining or accepting. Over time, we are learning about approaching clients with an opt-out option, rather than an opt-in approach."
Contact Ms. Goehring at (360) 725-2562 or firstname.lastname@example.org.