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Care coordination for Medicaid high-users
Program integrates, mental health, medical, issues
Medicaid recipients who are "frequent fliers" are getting help with their medical, behavioral health, and psychosocial needs through a pilot project developed by Hudson Health Plan and the New York State Department of Health.
The Westchester Cares Action Program demonstration project targets the state's highest-utilizing, highest-cost Medicaid recipients who receive fee-for-service medical care.
Westchester Cares Action Program provides face-to-face and telephonic care coordination for people in the project and receives a monthly fee from the state.
After the three-year project is completed, the state will compare the Medicaid beneficiaries in the Hudson health care pilot project to a control group to determine if there are cost savings and share the savings with the health plan.
The program integrates mental health, medical issues, and psychosocial issues and works to help participants overcome the barriers to improving their health, says Margaret Leonard, MS, RN-B, C, FNP, senior vice president for clinical services at Hudson Health Plan, a Medicaid managed care plan with headquarters in Tarrytown, NY.
"These are the most expensive patients on the state Medicaid rolls. From our experience as a payer, we believe that once we get these people stabilized and address their psychosocial issues as well as medical and mental health needs, we can make a big difference to them," she says.
When the program went live in August 2009, the state of New York gave the health plan a list of 250 Medicaid recipients with their last known addresses and telephone numbers, when available. The people were identified through an algorithm developed with New York University. The algorithm stratifies the beneficiaries and predicts their likelihood of needing services.
About 90% of the telephone numbers were incorrect or had been disconnected. Some people on the list were off the Medicaid rolls, had lost their eligibility, or enrolled in another program that made them ineligible for the Westchester Cares initiative, Leonard says.
Among the potential participants, 100% have chronic medical conditions, 75% have mental health and medical conditions, 72% have medical, behavioral health, and substance abuse issues, and 39% are homeless.
"Finding them has been very challenging. This is a transient population, and many of them use disposable cell phones so we don't have current telephone numbers for them," Leonard says.
The health plan contacts neighborhood shelters, clinics, halfway houses, soup kitchens, and other community organizations for assistance in locating the targeted beneficiaries.
Eight months after the pilot project went live, the health plan had located and enrolled about half of the 250 beneficiaries on the list provided by the state.
Finding the beneficiaries a second time is also a challenge, Leonard says.
"Sometimes they make an appointment and the person isn't there. Sometimes we never can reach them again," she says.
The project is staffed by nurses; social workers; intensive care coordinators, who are bachelor's-prepared, non-licensed people; and peer support specialists, people from the community who have been through the Medicaid system and understand the challenges of the people in the program.
The health plan held kick-off breakfasts at a local outreach program, shelters, and clinics to explain the program and recruit candidates for the intensive care coordinator and peer support specialists.
"We received a number of recommendations through the community-based organizations," Leonard says.
The intensive care coordinators make outbound telephone calls in an attempt to locate the people on the list or go to the beneficiaries' homes to look for them and enroll them in the program. Beneficiaries who enroll get a $20 gift card.
The intensive care coordinator sets up an appointment for a clinician to meet with the beneficiary and completes a comprehensive assessment within 15 days of enrollment.
"The staff go out in pairs for safety reasons. The nurse may go with the care coordinator, social worker, or peer support specialist," Leonard says.
The nurse enters the assessment into a computer program that includes an integrated health assessment tool.
The software analyzes each participant's areas of concern and outlines where the team should concentrate first, whether it's economic issues, psychosocial problems, mental health issues, or medical conditions.
Most of the time, team members have to work on solving financial and psychosocial problems before they can even start to look at the health problems of the beneficiaries, Leonard says.
"Coordinating care and making sure these beneficiaries follow their treatment plan is a tremendous challenge because there are a lot of psychosocial barriers. You can't get somebody to test their blood sugar every day or to take their medication regularly when they're shooting up, worried about their child, or homeless," she says.
Take for example, a beneficiary who was living with her unmarried daughter and her daughter's two children. The daughter stabbed the mother's boyfriend and was arrested. Under New York law, she was facing eviction from public housing because of the arrest.
The health plan intervened to keep the family in their home.
"We have to deal with issues like these before we can start on disease management. We've done a lot of things in this program that we've never done before. We've found housing for people; we've gone to court with them, or talked to their landlord about providing heat," Leonard says.
The case manager identifies what problems the participant faces and develops a care plan that encompasses his or her psychosocial, clinical, and mental health needs, then works with the participant to establish goals that are reachable, Leonard says.
For instance, keeping the blood sugar at a certain level is too difficult a goal in the beginning and would be overwhelming to the patient. Instead, the case manager will suggest daily monitoring and taking medication.
"Depending on what they decided, the case manager may follow up later in the day to make sure the participant did the things they decided on," she says.
The nurse or social worker and the intensive care coordinator work as a team and plan how to divide the work in coordinating care for the client.
If an intensive care coordinator has signed up a person, he or she will continue to be the main contact for the person and coordinate with the nurse. The team meets daily to discuss the patients, their progress, and what they need.
The team checks all medications the participant is taking and educates him or her on how to take them. The plan is to connect the participants with a medical home and help them follow their treatment plan.
Sometimes, a team will accompany patients to see the doctor for a physical therapy session or to the hospital. They have gone to the housing authority or to court with people who needed help in solving their social problems.
They provide transportation to doctors' offices whenever needed, teach the clients how to pay bills, and educate them on having a healthy diet.
They work to arrange housing for the homeless and to get addicts and alcoholics into treatment programs and support groups.
The intensive care coordinators make regular calls to the beneficiaries to ensure that they are taking their medicine and to make sure they don't need any additional assistance.
"This gives the participant someone else to talk to if they have questions and concerns. They can call into the program and talk to their case manager if they are having health problems or feeling anxious, and the case manager can make arrangements to see them the next day," she says.
The medication adherence piece and giving the participants someone they can talk to are keys to the success of the program, Leonard says. "We do a lot of hand-holding in this program, but these people have had a hard life. They don't know the system and need help finding ways to get their needs met," she adds.
It's too early to have definitive data, but anecdotal evidence shows that emergency department visits and hospitalizations have declined dramatically among participants.
For instance, two participants who were frequent utilizers of the health care system had just one hospital stay and two emergency department visits between them after participating in the program for seven months.
Hudson Health Plan's administration has been so impressed with the pilot project that it is launching a similar program to provide care coordination for eligible Hudson Health Plan members in its managed care programs.
In that program, the complete care program, nurses, social workers, and clinical assistants work with high utilizers to meet their psychosocial, mental health, and health care needs.