Programs for high-risk members save millions
Programs for high-risk members save millions
Program combines types of care
Passport Health Plan’s care programs for Medicaid beneficiaries has been able to show a cost savings of $191 million for the state of Kentucky in the eight years it’s been in operation.
The program provides a combination of health management, case management, and utilization management for complex, high-cost, at-risk members.
"We’re most proud of the fact that quality drives the cost savings. We have been able to show that quality and cost savings go hand-in-hand," says Helen Homberger, RN, director of medical management and Early Periodic Screening, Diagnosis, and Treatment (EPSDT) for the Louisville, KY-based HMO.
Passport Health Plan is owned by local hospitals and traditional safety net providers and contracts with AmeriHealth Mercy Health Plan of Philadelphia to administer its programs. The plan is a single-source Medicaid plan, serving 135,000 members — all Medicaid-eligible people in 16 counties in the Louisville area.
The health plan provides case management for populations at risk, including mothers and children, adults and children with disabilities, and members with chronic illnesses.
The case management department has nine nurses and two social workers, each carrying an average caseload of 45-50 members. Passport Health has a separate disease management program, which refers members to case management if they have extensive needs.
The case managers are all cross-trained to work with members with various diagnoses.
"Everybody has an area of expertise but all case managers have varying cases, even with special programs like HIV-AIDS, chronic obstructive pulmonary disorder, or palliative care," says Randy Simmons, RN, manager, case and utilization management.
In addition to helping coordinate health care for the members, providing member education, and encouraging members to follow their treatment plan, the Passport Health Plan case managers may help the member find housing, food, transportation, or assistance in paying for medication.
For instance, the case managers coordinated the care of an infant with respiratory problems who was ready to be discharged from the hospital but the home environment was inappropriate and was likely to exacerbate the illness, resulting in another inpatient stay.
The team worked with the housing authority and other community agencies to find housing for the child and his mother so they wouldn’t have to live with 12 family members, many of whom smoked.
"These types of activities separate what we do from more traditional types of case management," Homberger says.
Referrals to the case management program come from physicians, area hospitals, members themselves, and sources within the health care plan.
When the case managers receive a referral of a member for case management services, they make every effort to contact the members.
When members are referred to the program, the case managers try to contact them by telephone. If that doesn’t work, they go through claims data, looking for their last known address.
"This population is very transient. Their telephone number on the date of enrollment often is not valid by the time case management gets involved," Homberger says.
The case managers work closely with community advocacy groups to help them meet members’ needs.
"These members have so many psychological and social issues combined with their medical needs, that it is sometimes difficult to meet these needs because they are outside of the benefits coverage," Homberger says.
Educating members that they should be compliant with their treatment plan is a big issue for the Medicaid population, Homberger says.
"One of our greatest challenges is getting members to follow up with their primary care physician or a specialist on a routine basis rather than seeking urgent care for what could be handled in a physician’s office," Homberger says.
Medicaid beneficiaries may not be compliant with their diet because they don’t have the money to buy the right foods.
"We determine what is important to the member and begin to work on those," Homberger says.
Two of the plan’s programs are aimed at infants and children. The Mommy and Me Program goal is to improve the prenatal care and infant and maternal health of members. The Tiny Tots Transition Program helps promote a smooth transition to home for newborns with serious health conditions.
The two programs work hand-in-hand, Simmons points out.
When members are referred to the Mommy and Me program, case managers contact them by telephone, encourage early and regular prenatal care, and identify factors that could lead to pregnancy complications.
As a way to promote EPSDT, the program staff make phone calls or provide for visits through the Department of Health to the families of children who have not had the recommended EPSDT screenings, emphasizes to health care practitioners the importance of the visits, and sends postcard reminders to families of newborns.
Passport Health Plan provides a bonus to health care practitioners who achieve an EPSDT screening rate that meets the plan’s provider bonus goal. The staff visit the sites of the health care practitioner who serve a high volume of Medicaid members to review the requirements of the EPSDT program and help them compile and submit data.
As a result, 83% of children covered by the health plan received the required services in 2004.
Case managers working in the Tiny Tots Transition Program spend most of their time on-site at Level 3 neonatal intensive care units in local hospitals, managing the care of infants who must stay in the hospital beyond their mother’s discharge.
"They never know when the caregiver will be coming into the hospital, and they want to make sure they have a chance to talk with them to find out their needs and to set up the home visit," Homberger says.
Two case managers work with the neonatal ICU population at three hospitals.
"When we began the program in 2000, our initial thought was that this would be a utilization management program consisting of daily chart review for appropriate utilization. We found that the infants’ length of stay was not usually a result of a medical necessity issue. What these families needed was assistance with discharge planning to prepare them for the homecoming of the infants," Homberger says.
As soon as an infant is admitted to the neonatal ICU, the Passport case manager meets with the caregiver and begins working with them to prepare for the infant’s discharge. If needed, the case manager conducts a home visit and assesses the family’s needs, works to correct any environmental issues in the home to ensure that there is electricity, running water, and refrigeration in the home, and tries to get the parents in child-care classes if a need is identified.
"They work with the parents through discharge and follow the infant for at least 30 days, making sure the child has follow up visits with their pediatrician or neonatologist," she says.
If the baby requires addition case management after the 30-day post-discharge program, the hospital-based case manager refers the case to the case management department at Passport Health.
"We follow up with the member for any need for physical therapy or durable medical equipment support and to make sure they have someone they can contact with questions or concerns as well as to make sure they are established with a pediatrician," Homberger says.
The health plan measures compliance with primary care physician follow up, readmission rates, and emergency department visits for neonates in the program.
From 2002 through 2004, the average length of stay for newborns in the program fell by 28%. Emergency department visits after discharge dropped from 7% in 2002 to 4.5% in 2003.
Last year, the health plan had around 1,000 babies discharged after being in the neonatal ICU.
The HIV-AIDS case manager works closely with the medical staff at the Wings Clinic for HIV-AIDS patients, operated by the University of Louisville Healthcare System.
"HIV-AIDS is one the biggest challenges we have in managing care. The social stigma of the disease keeps people from going to the clinic because everyone knows why they are there," Simmons says.
The case manager makes regular visits to the Wings Clinic, may attend the appointments with the members, and works with the staff to assist with the member’s compliance with the treatment plan.
"The case manager at the Wings Clinic has developed a real rapport with the physicians as well as the office staff at the clinic. Through her efforts, members have become more compliant with their treatment plan and the clinic is better able to manage the member’s health care," Homberger says.
The member or the physician can request that the case manager accompany members to their appointments. The case manager contacts the members, talks to them about their apprehensions, and offers her assistance.
For instance, recently a member showed up for her first obstetrics visit when she was seven months pregnant, and tests determined that she was HIV-positive. She was referred to the Wings Clinic, which in turn contacted the Passport case manager.
"The case manager followed up with the member and helped her realize that the sooner she got started on her medication, the healthier the outcome for the baby. The baby was born HIV-positive but zero converted, which means a healthy outcome for the baby," she says.
The case managers may attend appointments with members and even accompany them to the drug store to make sure they get their medicine if needed.
Passport Health Plans care programs for Medicaid beneficiaries has been able to show a cost savings of $191 million for the state of Kentucky in the eight years its been in operation.Subscribe Now for Access
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