Peers help Medicaid patients comply with DM programs
Managed care/disease management
Peers help Medicaid patients comply with DM programs
The first step is understanding readiness to change
Case managers know it’s difficult enough to get mainstream group health patients to follow disease management programs. Imagine how much more difficult developing an effective disease management program would be if your patients were homeless. Two health plans have found that recruiting community members to work as peer outreach specialists reduces barriers to care in Medicaid populations.
"To get people to comply with disease management plans, you have to establish a strong bond with them," says Gabrielle Reed, PhD, RN, an instructor of medicine in the division of health behavior research at the Washington University School of Medicine in St. Louis, which runs an asthma management program for Medicaid patients. "You can’t walk into the community we serve and be white and middle class and hand down a medical prescription from on high. The people simply won’t hear you. Some are even homeless. They’re not ready to talk about asthma. We have to help them find housing first."
Washington University recruited young African-American women with children to work in its asthma management program. "We hire interested women right out of the community. It’s neighbors helping neighbors, and it begins with the enrollment stage."
When children are admitted to the hospital for asthma, their names and telephone numbers are given to two older African-American women who call the children’s families to explain the program and invite participation. "The voice on the phone is a recognizable voice. It’s comfortable to our moms," says Reed.
Dayton (OH) Area Health Plan also made a decision early on to establish a strong community presence for its Medicaid program. "We were one of the first Medicaid health maintenance organizations in Ohio. We needed a community presence, and we felt the best way to do that was to use members of the community in an appropriate way," says J. Diane Miller, RN, CCM, case management coordinator for Dayton Area Health Plan.
"Most of our members had very limited experience with health care systems. Many of these communities are very closed communities with internal standards for how to access health care and what type of health care to seek. We use community members to understand where members stand in their beliefs and attitudes towards health care so that we can plan our interventions more effectively."
Reaching out
Case managers help train community members to work as peer outreach specialists. Peer specialists at Dayton Area Health Plan complete a training program that begins with a basic orientation to the plan and its services and proceeds to field training with other staff members, says Miller. "We look for community members with a good knowledge of community resources and good communication skills. We often have to help members meet basic needs before we can tackle medical issues. We have to find them housing, clothing, furniture. Health care education has to be set aside until basic needs are met."
Case managers always are looking at costs and alternatives, Miller says. "Working with Medicaid populations requires a community presence, but it also requires flexible benefits. Sometimes, the most important benefit is not directly related to health care. It may be providing a homemaker for a single mother of four with a high-risk pregnancy. If it prevents a premature delivery, that’s a reasonable expense of a health care plan."
Physicians and nurses from Washington University train the asthma management program’s peer outreach specialists in basic asthma management, signs and symptoms of an asthma episode, and the stages of readiness model of health behavior change pioneered by researchers at the University of Rhode Island in Warwick. (See box, p. 39, for an explanation of the five stages of readiness. Also, see story, p. 39, for ideas on determining a patient’s readiness stage.)
"When we first explain the stages of readiness to our peer specialists, they immediately respond to it. They say it’s so intuitive," Reed says. "They easily sense which caregivers are ready to receive educational materials and make changes in their child’s asthma management, and which aren’t. If they aren’t ready, we work on eliminating barriers to behavior change and moving them forward."
The Transtheoretical Model of Health Behavior Change recognizes that patients vary in readiness to make health-promoting lifestyle changes needed for disease management. "If we pay attention to how ready people are to change, we don’t run the risk of patients tuning us out," Reed says.
Most of the research on the stages of readiness has revolved around health promotion programs. The key to successfully applying the model to disease management is carefully selecting the behaviors you target for change, she says. "You have to select behaviors that will actually produce health changes in your population." She suggests case managers use focus groups to select those behaviors and to "get your vocabulary right."
"When you finally get your patients to the point where they are interested, it’s great to have teaching materials appropriate to the population," she says. "And not only should the reading level and the language used be appropriate, but the illustrations should look like your target population."
Washington University targeted seven behaviors for its asthma management program, including these:
• The primary caregiver has a copy of the child’s asthma action plan.
• All other caregivers have been made aware of the child’s asthma action plan.
• The primary caregiver gives rescue medications according to asthma action plan.
• The primary caregiver brings the child in for regular four-month follow-up care.
• The primary caregiver eliminates or reduces the child’s exposure to secondary smoke and cockroaches.
"We know we’re sometimes fighting an uphill battle with issues like secondhand smoke. Even if the mom doesn’t smoke, she may leave her child with a grandmother who smokes while she works. She needs her mother to baby-sit, and we come in saying, Don’t you realize that smoke is bad for your child?’" says Reed. "If peer specialists look at that mom’s face and see from her expression that she’s not ready to make that change, they start talking around that issue. They plant seeds of information. They challenge the moms to figure out how to make things work.
"Nobody makes changes unless they think they’re going to work," she adds. "Facts and figures don’t go over well until somebody believes you."
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