Tap underutilized resources for care coordination of children

State Medicaid programs are taking various approaches to promote care coordination for young children, but few utilize existing maternal child health hotlines or web-based referral strategies. Researchers from the National Academy for State Health Policy (NASHP) in Portland, ME, identified strategies to improve community linkages in their December 2009 report "State Strategies for Care Coordination, Case Management, and Linkages for Young Children: A Scan of State Medicaid. Title V, And Part C Agencies."

Linkages within primary care practices, between primary care practices and other child and family service providers, and through systems or statewide strategies were identified. The fact that few efforts built on existing maternal child health hotlines was somewhat surprising.

"This is an area that may represent an underutilized resource that some states may want to add to their care coordination strategies," says Jill Rosenthal, NASHP's program director.

Similarly, given that many states already have well-developed web capacity, web-based referral strategies may be another obvious approach to improve care coordination. "Although budget issues may hamper efforts, opportunities through federal stimulus funds and a current federal emphasis on improving health information technology may help enhance some of these strategies," says Ms. Rosenthal.

Strategies for care coordination

Through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program, state Medicaid agencies play a major role in the policy and financing of children's primary health care. "State Medicaid agencies can use this important payer position to strengthen care coordination, particularly at the practice level," says Ms. Rosenthal. This could be done by implementing medical home models, setting quality improvement and performance standards, and using electronic medical health records.

Ms. Rosenthal gives the following approaches by which Medicaid policies can support cross-system linkages and improve care coordination for children:

— giving enhanced reimbursement to support case management activities of medical home providers who care for children;

— funding community-level care coordination staff, such as EPSDT county staff;

— implementing reimbursement policies that support provider guidance, billing codes, and graduated/tiered fee schedules;

— having mechanisms to track referrals from EPSDT well-child screening visits, allowing states to pay bonuses to providers with high rates of completed referrals;

— partnering with other state agencies to finance or provide technical assistance for cross-systems training, family support, parenting education, or similar programs;

— making Medicaid financing part of a "braided funding stream" to finance child health and mental health consultants for early care and education programs. For example, Medicaid can finance the mental health intervention services provided to a child if the child, provider, and service are all eligible, even if the services are provided in a child care center;

— evaluating the availability and quality of care coordination services. "To enhance linkages, it is critical for Medicaid agencies to partner with other state agencies such as early intervention and mental health, as well as with providers and communities," says Ms. Rosenthal.

Some big obstacles

One potential barrier is that primary care providers may lack the time or resources to link patients with community resources. They may be unfamiliar with nonmedical services, and there may be gaps between service delivery systems that are driven by policy, program design, or categorical funding. Along these lines, funding, resources, and reimbursement were the biggest barriers cited by states in the NAHSP report, followed by fragmentation of programs.

"There are dozens of programs administered by seven federal departments that deliver services to children," says Ms. Rosenthal. "Medicaid, child welfare, mental health, public health, education, and other state agencies have overlapping missions and serve overlapping populations. These complex systems and agencies were created separately at the federal level. They typically operate independently of each other, unless explicit policies and projects call for integration."

Tracy J. Plouck, Ohio's Medicaid director, says the department has a number of care coordination and case management services for Medicaid consumers, who include children. The most recent initiative, implemented in 2009, is a statewide performance improvement collaborative with Medicaid managed care plans. The goal is to improve access to EPSDT services for children under 21.

"The performance improvement project collaborative is designed so that all of the managed care plans implement the same standardized member and provider-focused interventions and measurements," says Ms. Plouck. The goal is to optimize health outcomes and improve efficiencies related to health care service delivery.

"Ohio faces the same issues as most states across the country, with restricted resources and increased demand for services," says Ms. Plouck. "Despite this set of circumstances, Gov. Strickland has remained committed to Ohio's most vulnerable citizens and has maintained Medicaid eligibility and funding to preserve health care services."

In addition, an evolving statewide collaboration will support initiatives that achieve measurable improvements in children's health care and outcomes. "This collaboration began with an initial project focused on optimizing developmental outcomes for young children, and grew as we learned about similar work in other states," says Ms. Plouck.

Medicaid clients living in Utah's four urban counties are required to enroll in one of three health plans. These are the managed care plans Healthy U and Molina Healthcare, and Select Access, a preferred provider network. "The Quality Assessment and Performance Improvement Plan (QAPIP) is the state monitoring tool for contracted health plans," says Wanda Gutierrez, Quality Improvement Specialist for Utah's Department of Health. Healthy U and Molina are required to do the following:

— Conduct basic health needs assessments to identify enrollees with special health care needs and those needing case management services. Based on the results, clinical staff conduct more detailed clinical needs assessments.

— Have other ongoing mechanisms to identify clients needing case management services after enrollment.

— Operate a case management program to assess and facilitate access to needed care, coordinate care, promote adherence to treatment plan, and ensure quality, timely, and cost-effective outcomes.

— Annually assess the effectiveness of its case management program.

— Have procedures to determine the frequency and duration of case management services, and assess if resources are adequate.

— Have protocols to address noncompliant members and coordinate with other state and community agencies.

— Track case management services.

The Select Access contract requires it to provide pediatric continuum-care case managers to screen high-risk pediatric members up to age 19 to assess their social, medical, and educational needs. "The case managers compile all relevant data and information related to their needs and coordinate with an interdisciplinary team to develop a plan of care that is designed to optimize outcomes," says Ms. Gutierrez.

As a result of these initiatives, Ms. Gutierrez says she expects to see more appropriate utilization of services, improved outcomes, and better access to available health care services for at-risk populations.

While the health plans have effective care coordination programs —because it is federally required under managed care regulations—care coordination is not required for the general Medicaid population who are not enrolled in a health plan. "There are limited resources and funds to implement care coordination outside of managed care," says Ms. Gutierrez. "For Medicaid members not enrolled in managed care, at-risk populations are at a disadvantage without the added assistance of someone overseeing, coordinating, and helping to facilitate needed health care."

Contact Ms. Plouck at (614) 466-4443.