Collaboration between providers, patients, payer helps reduce gaps

Health plan, hospital project focuses on Medicaid members

A collaborative effort between Keystone Mercy Health Plan and local hospitals to provide care coordination for Medicaid members is helping reduce health care gaps and emergency department and inpatient utilization.

"The Medicaid patient population is uniquely vulnerable in that they tend to have multiple chronic conditions. They use multiple doctors, typically have more than seven medications prescribed, and frequently come on and off the plan. Many of them seek treatment at the emergency department even though they have a primary care provider assigned. Our preliminary data show that by coordinating care between the patient, the payer, and the provider, we can help the members stay healthier and receive the care they need in the appropriate setting," says Diana Rappa-Kesser, RN, MSN, CCM, senior director for care coordination for Keystone Mercy Health Plan, a member of the AmeriHealth Mercy Family of Companies.

Initiatives include placing health plan case managers at two primary care offices and placing a transition manager at a hospital to assist with coordinating the care of Medicaid patients in the emergency department and to help with inpatient discharge planning. Another initiative includes the development of a community outreach team to assist in reaching members who are difficult to find or who have disconnected phones, and then coordinating appointments with primary care physicians.

Before the project began, the care coordination team at Keystone Mercy Health Plan worked with a health system in southeast Pennsylvania, to determine how to impact health care services for the Medicaid population.

Preliminary data at one practice site showed that 60% of the membership had care gaps, some for preventive services and some related to specific diseases, Rappa-Kesser says.

"These are the most vulnerable citizens in the area. We looked at ways to get them connected to a primary care home and to avoid hospital admissions and their use of the emergency department. We wanted to decrease inappropriate utilization of the emergency room, and inpatient admissions, and improve clinical outcomes," Rappa-Kesser says.

The collaborative effort between the health plan and the primary care provider has closed 90% of the gaps for patients in that practice, she adds.

Initially, Keystone Mercy Health Plan placed Lynne A. Major, MSW, LCSW, CCM, social worker case manager, at an ambulatory care clinic one day a week, where she worked with one provider who ran a residency program. The majority of patients at that clinic are insured by Keystone Mercy Health Plan.

Major now continues to work at the clinic four days a week and collaborates with several providers to address health care gaps.

As an employee of the health plan, Major has real-time access to health care information that the clinic physicians didn't know about. For instance, she has pharmacy data, information on emergency department visits, and hospitalizations that the physician may not have received.

"She can see if the members are slow to fill their medications or if they go to another hospital that isn't in our system. She is the conductor of the orchestra who pulls all the pieces of information together so the primary care physician in charge can coordinate care," Rappa-Kesser says.

For instance, Major uses claims data to inform the physician if the member has been to the emergency department multiple times, if he or she has been hospitalized, and what the diagnosis was.

"When a patient has an appointment, I give the information to our pharmacist, who sends me three months of pharmacy data so we can tell if the patient's pattern in filling and refilling the prescriptions is fitting in with what the doctor is prescribing, and if another physician also is prescribing medication," Major says.

Seeing the members face-to-face has been key to the success of the program, Major says.

"We've been doing telephonic case management with these members for years. However, when I see them face-to-face in the clinic, I can connect with members holistically and see the other problems they may have in addition to their chronic diseases and comorbidities. Then I can work with the member and the physician to create a plan of care that will work for that patient," she says.

"I've developed a relationship with many of the members that just isn't possible with telephonic case management," Major says.

"I know them, and they know me. They often stop in on days they don't have an appointment and ask to see me if they have a question or a concern about their health. The members know that they have support. They have learned to trust me and to bring more issues to the forefront," she says.

Major determines if patients have had preventive care measures and works with the physicians to deal with other problems, such as psychosocial issues that are barriers to the member receiving care and following the treatment plan.

For instance, some members are consistent no-shows, making appointments and canceling them.

"I do outreach and work with them to address the problems and barriers that prevent them from coming to see the doctor," she says.

When patients don't show up for appointments, Major drills down to determine the reason. It may be that they are experiencing problems with housing or having enough food to eat, or that they don't have transportation.

"We can complete a transportation application in the office almost immediately. A lot of things can happen quickly when everybody is in the same place at the same time as opposed to trying to get the physician involved by telephone," she says.

Sometimes, Major works to solve internal problems, such as those that result from the health plan's formulary.

For instance, some medications need prior authorization, but the physician may not know it so the member is unable to get the prescription filled. In other cases, the medication prescribed is not in the health plan's formulary and won't be covered.

"We want to avoid having the member leave the office without getting what he or she needs. I work with the physicians to get prior authorization for medications that require it and to prescribe alternative medications that are covered by the plan," she says.

Some members don't have a pharmacy benefit to cover their medications. In this instance, Major works with the physician to find an alternative medication that is available at affordable prices through programs at retail stores, such as Wal-Mart and Target, or connects the member with pharmaceutical assistance plans.

"Not only do I work within the system, but I also access external services to make sure the patients get what they need," she says.

Through the years, Major has compiled an extensive list of community resources.

"Our company provides us with resources and in-service programs to keep everybody up to date on what's available. I work hard to stay on top of it because I never know what the members will need — whether it's food, clothing, housing, transportation, or help with domestic violence issues," she says.

Major keeps in close communication with the health plan's transition manager.

"I let her know if someone has been seen in the clinic and sent to the emergency department for evaluation or admission. She makes sure that we are aware when one of our members is being discharged and works together with the hospital case manager or social worker to make sure the patient has the needed home care or equipment," she says.

The case manager at Mercy Fitzgerald works primarily in the emergency department and also visits Keystone Mercy members on the unit to assist with discharge planning and ensure that there are no gaps in care.

"She makes sure that patients who have been hospitalized have a timely follow-up appointment with their primary care physician. When she notifies me about someone who has been discharged from the emergency department, I follow up and make sure they get back to see the doctor," she says.

The clinic has some appointments set aside for people from the emergency department who don't have a primary care physician.

"If a member is just out of the hospital or has been to the emergency department or they call and say they're sick, I can advocate with the office staff for a quick appointment," Major says.

The health plan has just placed another care manager at a clinic in west Philadelphia to work primarily with the uninsured population.

"In addition to ensuring that these patients have a follow-up visit, we're working with two hospitals and pharmacies to make sure they leave the hospital with the medication they need and that home care is in place. A lot of times, heart failure patients don't get their prescriptions filled or don't understand their treatment plan and end up right back in the hospital," Rappa-Kesser says.

When one of the case managers working at the physician practices can't reach someone who has missed an appointment or is due for a test or procedure, she calls on the Community Outreach Support Team for help in locating the member at his or her last known address or neighborhood community resource sites.

The Community Outreach Support Team is made up of laypeople who live in the communities where many of the Medicaid members reside and are employees of the health plan.

"We're trying to bridge all of those places where our Medicaid members have a potential to fall through the cracks. Our goal is to have members return to their primary care physician's office. We want to help the members adhere to their treatment plan and stay healthy and at the same time reduce inappropriate health care utilization," Rappa-Kesser says.