Program helps Medicaid recipients learn to navigate health care system

Care management approach saves agency money

Faced with a legislative mandate to save $2.5 million over the 2004-2005 biennium, Montana Medicaid developed a three-pronged approach to helping its clients better manage their health.

Components of the agency’s care management program are Nurse First Advice Line, Nurse First disease management services for patients with certain chronic diseases; and the Team Care program, which provides education and strict case management to the most frequent users of health care services who have no underlying medical cause.

In addition, a group of patients, primarily with congestive heart failure, are piloting Health Buddy, a remote monitoring program.

Montana Medicaid’s Nurse First is administered by the Montana Department of Public Health and Human Services (DPHHS) and McKesson Health Services, serving approximately 63,000 Montana Medicaid recipients.

The agency shifted to a care management approach when faced with significant increases in Medicaid enrollment and utilization, reports Mary Angela Collins, Medicaid managed care bureau chief.

Preliminary analysis of the care management program indicates the agency will meet and possibly exceed its cost-cutting goals, she adds.

The Nurse First program, available on a voluntary basis to the majority of Montana Medicaid clients, is a 24-hour-a-day, seven-days-a-week registered nurse advice line with the goal of directing clients to the appropriate level of services at the appropriate time.

Eligible clients are encouraged to call Nurse First any time they are sick or hurt. The nurses ask about symptoms and health concerns, then triage the callers using clinically based algorithms to help the client decide the best time and place for care, or provide self-care tips if appropriate.

The client call-in rates by Montana Medicaid recipients have been the highest experienced by McKesson Health Solutions, which operates Nurse First.

The nurse line is supplemented by a traditional disease management program for Medicaid clients with chronic illnesses, including asthma, diabetes, congestive heart failure, and chronic pain.

The voluntary disease management program includes individual counseling, telephonic interaction with registered nurses, and face-to-face visits when necessary.

The most innovative aspect of the program, Team Care, concentrates on providing assistance to approximately 300 users of extremely high levels of Medicaid services with no underlying medical cause for their high usage.

The participants are instructed to call the Nurse First advice line for triage before seeking any medical treatment or scheduling an appointment with a physician.

The agency looked at putting a 10-visit limit on trips to the doctor to save the money mandated by the Montana Legislature but decided to try a different approach that would have the added benefit of helping Medicaid recipients better manage their own care while saving money, Collins adds.

"We started with the most egregious examples of people who overutilize the emergency room and physician visits and put them into the Team Care program. We tell them that we are going to work as a team to help them learn to access medical resources more efficiently," she says.

The DPHHS identified the candidates for the program by analyzing claims data, looking for people who make 25 or more physician visits or 12 or more emergency department (ED) visits in a year.

"There are a significant number of Medicaid recipients who visit their doctor 25 times a year or more with no medical reasons. Some are going twice a week for allergy shots, but others have no medical condition that would warrant it," Collins reports.

Montana’s Medicaid recipients who are in the Team Care program make 25-100 or more physician visit or multiple trips to the ED and fall into four basic categories:

  • People with mental health problems.

The Nurse First nurses provide support to these patients, helping them to identify community resources that can help.

"We think we can help these people learn to make better health care decisions, once we identify them and their problems," Collins says.

  • People who don’t know how to use the system.

This includes mothers with young children and no family resources who think they should take their kids to the doctor for everything and people who use the ED as a primary care provider.

"We are sure we can help them develop better ways to access health care by getting them to call Nurse First, sending them mailings, and making follow-up calls," Collins says.

  • People who use medical care as a substitute for a social life.

"These people are lonely and need attention. The Nurse First line can give them the kind of touches they need. We’re not sure we can eliminate their pattern, but we can at least moderate it," she says.

  • Hard-core drug seekers.

"We have no illusions that we can change the behavior of this group. All we can do is restrict them," Collins says.

Before placing the candidates in the program, the agency sends a letter to their physicians asking if there is a reason that the patients are justified in making so many visits. In some cases, the physician has replied that a patient has a condition that is not recognized by claims analysis that requires frequent physician visits.

Claims data identified about 80% of the candidates, Collins says. The agency’s Drug Utilization Review board and providers also identified some candidates.

"We told our providers that they know better than anybody who is using services they don’t need and asked them to refer any patients who could benefit from restrictions," she says.

The agency sends people identified for Team Care a letter telling them they have a team available to give them extra assistance in accessing the health care system.

"We want to be nice but at the same time let them know that life is going to be a little different. Instead of calling their primary care physician first, like in the past, they need to call the Nurse First line first," she says.

Team Care participants must choose one primary care physician and one pharmacy and are locked out of other pharmacies, decreasing the possibility of drug abuse.

When a Team Care participant calls in, the Nurse First nurse is automatically alerted.

Physicians respond positively

The Nurse First nurses take a slightly different approach to the Team Care patients than the one they use with other Nurse First callers. "We present Team Care as something we can do to help the clients. The biggest challenge we have is to get the people who need the Team Care service to like it and not be resistant. We don’t want the nurses at Nurse First to be the bad guys. We want our clients to continue to call the Nurse First line," Collins reports.

Over time, if the soft-pedal approach doesn’t work, the agency can add more restrictions, she adds.

When clients in the Team Care program call into the Nurse First line, the nurse talks to them about their condition to find out the symptoms they’re experiencing. If the symptoms don’t warrant medical care, the nurses advise them to stay home and take care of the symptoms.

The nurse then sends a fax to the primary care physician, telling them the patient’s complaint, symptoms, and their recommendation.

"We still give the client the ability to upgrade the recommendation. The nurse makes sure the person understands self-care and feels comfortable with it, then tells them if they feel it’s absolutely necessary, they can call the doctor," Collins says.

Then it’s up to the physician to decide whether to make the appointment.

"The doctors can tell the patient that they were triaged by the Nurse First line and told that they didn’t need to see a doctor. If the doctors want to make the appointment anyway, we will still pay them," she says.

The physicians have responded positively to the program because the Team Care patients make up their problem population.

To help cut down on clients who use the ED instead of their primary care physician, the agency developed wallet cards for the all of the Montana Medicaid clients, instructing them to call Nurse First if they’re sick or hurt. They make the cards available to hospital EDs. "Emergency departments are reluctant to turn people away, even if all they have is a cold. This way, they don’t have to lecture the patient. They can give them the card and tell them to call Nurse First next time instead of coming to the emergency room," Collins says.

The data already have shown that some clients enrolled in the Team Care program have cut their ED visits by 75%, she adds.

The agency anticipates saving as much on the first 300 enrollees in Team Care as the Nurse First advice line saves with 63,000 members.

The Team Care pilot project began in August 2004 with 100 enrollees who were identified by claims data, drug utilization review, or referrals by medical professionals, then grew to 300 participants. Montana Medicaid plans to expand the program to include an additional 300 participants after another staff position, approved during the last Montana Legislative session, is filled.

"The Team Care program is very labor-intensive. We have one staff person who deals with all the clients who call, as well as their providers. These people have very personal needs and they need a lot of touches," Collins says.

Over time, DPHHS plans to automate parts of the system to save the staff time and enable the agency to expand the program to more clients, she says.

The Nurse First program started Jan. 1, 2004, with the disease management piece rolling out during the first quarter of the year.

"The Nurse First nurse line is so effective for people who are conscientious and don’t want to go to the doctor if it’s not necessary. It’s working as well for those who go too much," Collins says.

The nurse line also is helpful to many Medicaid clients who live in rural areas where it’s as much as 100 miles to the closest hospital.

"A lot of clients love being able to call the nurse line and help avoid an emergency room visit if they can. Even when it’s not that far, it’s easier to pick up the phone than to drive 10 miles in the snow," Collins says.

The Nurse First line already has saved lives. For instance, a woman in a small town outside Billings called, complaining that her chin and neck hurt.

"She thought it was probably nothing; but in talking to her, the nurse determined that this caller was having a major heart event," Collins says.

About 6,000 Medicaid recipients with chronic conditions are offered intensive traditional disease management services.

The disease management nurses complete a health assessment and make follow-up calls. In cases where the patients are severely at risk, a nurse may visit them at home.

The agency is piloting Health Buddy, a remote monitoring system, with its congestive heart failure patients.

The patients attach the device to their telephone and use it every day. The small machine asks a series of questions, such as "Have you weighed yourself?" "How much do you weigh?" and "How do you feel on a scale of 1 to 5?"

When the patient enters these data, the call goes directly to a disease management nurse if there are any red flags. The nurse talks to the patient, makes a recommendation, and contacts the health care provider when appropriate.