Creative solutions engage Medicaid patients in disease management

Bilingual nurses, counseling pay off with publicly insured population

Medicaid recipients with chronic diseases are a difficult population to reach. Often, they're transient and face economic, linguistic, and cultural barriers to health care.

That’s why McKesson Corp., based in San Francisco, came up with a series of outside-the-box initiatives in its disease management programs for Medicaid patients whose care is not covered by a managed care contract.

"Disease management has undergone an exciting revolution in caring for the chronically ill population, particularly those in vulnerable populations where the services didn’t exist two years ago," says Sandeep Wadhwa, MD, vice president of medical management services at McKesson.

McKesson has established Medicaid disease management programs in Colorado, Washington, Oregon, Florida, Mississippi, and Montana using registered nurses who do telephonic disease management and collaborate with the patients’ physicians, complemented with field nurses who do face-to-face counseling, educating the patients on self-management.

"Those Medicaid recipients don't have the benefit of the infrastructure provided by a managed care contract. We can contract with the states to provide disease management without a full managed care contract," Wadhwa says.

When it made the commitment to offer disease management programs for the publicly insured, McKesson took its successful programs for its commercial population and tweaked them to meet the needs of the Medicaid population.

"We’re not married to everything being done by telephone and by a registered nurse. A big part of our model is to overcome barriers to engagement with chronically ill patients," he says.

Through the use of "community locators" who help find patients with no permanent address, bilingual nurses, and local pharmacists who help enroll patients, the company has engaged a much higher percentage of participants among Medicaid recipients than among its commercial populations.

Only about 5% of the Medicaid population chooses to opt out of the disease management programs, a much lower percentage than in McKesson's commercial programs.

McKesson offers disease management services for the big five diseases: asthma, diabetes, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease.

In some states, the company handles disease management for all five conditions. In others, they contract to manage only some populations.

The state of Washington, one of the first states to implement the program, has projected $2 million in savings in the first year. The state reports that 26% of its Medicaid recipients with asthma have an asthma action plan, compared to 11% the previous year; 30% of diabetics have a diabetes action plan, an increase from 17%.

Overall, participants in McKesson’s Medicaid disease management programs have shown a 20% increase in flu vaccination rates, an increase in inhaled steroid use among asthmatics, and an increase in ACE inhibitors for heart failure patients.

Here are some of the created initiatives McKesson uses to engage the patients:

Community locators

Recognizing the challenge of contacting people who often have no permanent address or telephone number, the company employs locators who often are community leaders who are familiar with the people in their neighborhoods.

"They are nonclinical people but are interested in health care and are bedrocks of their communities. They fill a valuable role in helping our nurses find the patients," Wadhwa says.

Identifying the community locators is "half networking and half direct job soliciting," he says.

The company runs employment ads in the newspapers in areas where there are high concentrations of Medicaid recipients. They meet with advocacy groups and set up informal networks to get names of people who would be interested in helping locate Medicaid recipients.

The locators network with homeless shelters and community soup kitchens, using a model borrowed from the tuberculosis public health program. "We use whatever community resources we can identify to be go-betweens to connect the clinical community and a vulnerable mobile medical population," he says.

Bilingual nurses

The company often employs bilingual nurses who can communicate with patients in the prevalent language in that community.

"We get much greater participation and a higher comfort level when the nurses can communicate directly with the patients rather than relying on interpreters," Wadhwa says.

The company often utilizes nurses who speak the five primary languages identified by the state. A call center in Puerto Rico helps McKesson meet the needs of the Spanish-speaking population.

Pharmacy partnerships

In Washington, McKesson has partnered with Rite Aid on a pilot project to offer services right in the drugstore and to enroll eligible patients.

"A lot of drug stores are at major intersections and act as community landmarks." Wadhwa points out. When eligible patients go to the pharmacy to refill prescriptions, the pharmacist can enroll them right on the spot. "We recognize that pharmacists are another constituent. They deliver a lot of care to Medicaid patients. We are piloting this program with Rite Aid and plan to study ways to improve the concept and open it up to other pharmacies," he says.

In some instances, the field nurses meet with homeless patients in the drug store.

Sensitivity to local language, accents

McKesson can set up a call center if appropriate in states it serves, so Medicaid patients will hear a familiar accent on the telephone. "We recognize that there is a sensitivity about outsiders with the Medicaid population, and local accents make a difference. Patients in Mississippi feel more comfortable when they get calls from someone with a Mississippi accent, and they’re more likely to work with them than if they're called by someone with a Colorado accent," Wadhwa says.

The key to a successful Medicaid disease management program is to be flexible in each marketplace. "What works in Mississippi may not play in Oregon," he says.

Partnering with the community

The company works with community agencies to provide services for the patients. For instance, the American Lung Association in Washington state had 2,000 bed covers and asked McKesson to help identify asthmatic children on Medicaid who could use them. The disease managers work closely with physician groups and partner with community health centers as a way of locating patients and as a place where they can do patient education.

"We find that we are in kind of a catalyst role in terms of organizing different stakeholders in a community. We work with the community health centers, which gives us more access to all regions," Wadhwa says.

Home visits

Whenever possible, the field nurses meet the patients at home so they can check for safety issues as well as educating the patients. "We think there is a lot of value in home-based care. For instance, the nurses can provide a little more education on dietary issues if they can open up the refrigerator and discuss what's inside," he says.

In the case of homeless patients, the nurses meet them at the public library, a physician’s office, or a pharmacy.

Identifying a primary care provider

The major thrust of the program for the first few months is to help the patients find a medical home. Many of them can't identify a provider who serves as coordinator of their care.

"Before we start the educational portion of the program, we help them identify a physician they will be comfortable with who will communicate with and reinforce the care with us," Wadhwa adds. The disease management nurses make sure the patients get to their appointments and prepare them with questions about the medications they are taking, potential side effects, and what tests they may need.

"The disease management nurses may spend an hour talking with a patient about blood pressure, and at some point, something clicks and their past eight doctor visits make sense. The doctor finds that the patient is much more understanding of the goals of therapy and that some of the frustrations have been removed," he says.

Physicians report that patients who are in the program are more active in participating in their own care and that no-show rates drop and after-hours calls go down after patients enroll in a disease management program.

"We are looking for ways to help doctors who are taking Medicaid payments," Wadhwa says. Because Medicaid reimbursement often is lower than what physicians receive from commercial payers, McKesson tries to help show that the state Medicaid program wants to make it easy to treat the patients.