Special-needs patients require broad care coordination, according to new study

Enrollment of increasing numbers of beneficiaries with special needs in Medicaid managed care programs is leading some states to develop broad care coordination programs to deliver both medical and psychosocial services as efficiently as possible.

In a policy brief summarizing a study conducted for the Center for Health Care Strategies, Margo Rosenbach, vice president for Mathematica Policy Research in Cambridge, MA, says comprehensive care coordination "enables people with special health care needs, especially those with chronic conditions, to navigate through complex Medicaid managed care systems. A relatively new trend, care coordination can include brokering for social support and medical services, breaking down boundaries between systems of care, assisting families with transportation and telephones — in short, whatever it takes to keep patients at home and healthy."

Ms. Rosenbach tells State Health Watch that some states are pursuing "overlays" in Medicaid managed care to put more emphasis on a broad coordination of care.

"Some states have broken down the boundaries between what is health care and what isn’t. For example, having a phone installed that can be used in an emergency may mean the difference between a person being institutionalized or being able to stay at home."

If individuals are able to function better as a result of a broad concept of care coordination, Ms. Rosenbach says, that will lead to a long-term reduction in health care costs.

Care coordination programs work best with a stable patient population, she says.

Several states involved

The Mathematica report was based on interviews with officials and advocates in Colorado, Delaware, New Mexico, Oregon, and Washington. At the time of the interviews in 1999, there was no standard definition of care coordination and thus those interviewed were asked to define the term and indicate how care coordination differs from care management in their program or experience.

Ms. Rosenbach says that although the differences are presented as a dichotomy, they really exist along a continuum, with some features more or less dominant depending on program structure.

Case management programs typically rely on a medical model that focuses on a patient’s health care, while care coordination programs tend to use a broader social service model to consider a patient’s psychosocial context such as housing needs, income, and social supports. Case management programs tend to coordinate services internally, focusing only on covered services, while care coordination programs may coordinate a full range of medical and social support services offered within and outside a managed care plan.

As a result, care coordination programs typically arrange covered and uncovered services for patients.

For managed care organizations, coordination of noncovered services may be the most important factor differentiating care coordination from case management.

Ms. Rosenbach says that from her interviews, two particular lessons stand out for those interested in implementing a care coordination effort. First, care coordination programs take time to develop. States need to allow enough time to work with managed care organizations, providers, and advocates before implementing Medicaid managed care for people with special health care needs.

She says it is unrealistic to expect managed care organizations to develop care coordination services at the same time they are enrolling new members.

The second important lesson learned is that care coordination can be implemented even after a state has implemented Medicaid managed care.

In Delaware, she says, the Medicaid agency introduced care coordination for children with special health care needs about four months after they were enrolled in managed care, after advocates and families had raised concerns about discontinuities in care.

While managed care organizations vary widely in their approaches to designing care coordination models, Ms. Rosenbach says she was able to identify three generic models:

  1. a centralized team model, generally involving nurses and social workers, in which all care coordination staff are located at a managed care organization’s central office;
  2. a regionalized model in which staff are assigned to specific geographic areas;
  3. a provider-based model in which staff are assigned to support specific provider groups.

Even within the three models, she says, managed care organizations have been very flexible in designing hybrid models and defining staff responsibilities.

Some managed care organizations make use of outside resources to help support their care coordination programs. (For a checklist of items states need to consider in implementing a care coordination program, see box, p. 4.)

Ms. Rosenbach’s report says that anecdotal evidence suggests that the care coordination concept is well received within Medicaid managed care programs.

Six challenges that must be addressed are:

  1. bridging confidentiality barriers experienced by managed care organizations;
  2. addressing boundary issues between managed care organizations and other agencies;
  3. increasing knowledge about the availability of care coordination services;
  4. developing standardized tools for assessment and care planning;
  5. setting appropriate rates to cover the cost of care coordination services;
  6. evaluating the effectiveness of care coordination services.

Oregon’s program has been very successful, according to Joan Katowich, program and policy manager in the state’s Office of Medical Assistance Programs. Contracts with managed care organizations call for them to have someone on staff to handle care coordination in a combined medical and social model.

Ms. Katowich says the program developed with broad goals but without the state agency prescribing how the goals were to be met.

"We have a framework through which managed care members can be placed in the community in ways that the organizations thinks will work best," she tells State Health Watch. The care coordinators meet with the state agency staff several times a year to share problems and best practices.

The program was not set up to meet a specific cost-benefit goal, Ms. Katowich says, and it’s not an easy thing to define.

"We didn’t want people to spend a lot of time justifying their existence." In later years of the program they have obtained a lot of anecdotal information from members indicating the success of the program, even to the point that a dying patient asked that his care coordinator be with him in the final days. There also is a lot of informal coordination that sometimes takes place for patients who are not eligible, she says.

Oregon gets creative

Managed care organizations in Oregon have taken varying approaches to the problem, with some using nurses and others using social workers.

"It’s an intimate program. The coordinators are involved in solving both small and big problems. They sometimes arrange for transportation and sometimes help patients divide medications by color. They’ve arranged for developmentally disabled members to live at home with hospice care, Ms. Katowich says. "Their job and ours is to keep the support going."

Delaware’s program for children from birth to 3 years old has been around for many years, according to Nancy Colley, manager for the Early Intervention Program.

"Integration of services depends on the need," she tells State Health Watch.

The program uses the services of case managers, developmental health specialists, public health case managers, developmental specialists, and the state Department of Public Instruction. Children were identified for the program based on the ICD-9 codes that qualified them for developmental services.

[Contact Ms. Rosenbach at (617) 491-8044, Ms. Katowich at (503) 945-6500, and Ms. Colley at (302) 995-8576.]