Patient at the Center
Programs for Adults with Special Needs
Minnesota Disability Health Options: Integrating Care
and Improving Health Outcomes
Ron has lived with multiple sclerosis for more than 20 years. When he developed a severe skin ulcer two years ago, several days elapsed before a home care nurse treated him. As a result, the condition worsened and he needed surgery. After surgery he spent nine months in a nursing home. Like Ron, many Medicaid beneficiaries with physical disabilities have sporadic access to care coordination or integrated services. Without appropriate case management, many beneficiaries receive fragmented specialty care and infrequent primary care, and often incur costs that may have been reducible, or perhaps preventable.
In hopes of alleviating this problem, the Minnesota Department of Human Services created the Minnesota Disability Health Options (MnDHO) program that integrates delivery of all Medicaid and Medicare services. The innovative program, which contracts with AXIS Healthcare to provide care coordination and case management, focuses on holistic, self-directed health care. Upon enrollment, AXIS conducts a comprehensive assessment, investigating everything from the enrollee's medical history to the name of his/her pet. The enrollee and a health care coordinator work together to design a personalized care plan, which maintains the patient's ability to live in the community.
Since its inception in September 2001, approximately 300 working-age Medicaid-eligible individuals with physical disabilities have enrolled in MnDHO. Results show that the program is improving the overall health of enrollees:
* Hospitalizations have more than halved.
* Hospital lengths of stay decreased by more than 60 percent.
* Ninety percent of members reported satisfaction with their health care services.
* Eighty-five percent of enrollees reported receiving help with managing their health care services.
Ron is overwhelmingly satisfied with MnDHO, and AXIS Healthcare in particular. While at the nursing home, he and Patty, his new health coordinator, created a plan, including home modifications, which helped him return home. When Ron suffered another skin breakdown a few months later, Patty visited him the day he called. Ron was fully healed within a few weeks.
Contacts: Chris Duff, Director, AXIS Healthcare, 651.556.0863; Deborah Maruska, Coordinator, MnDHO, 651.296.0825; Ron or another member, (identified through Chris Duff)
Horizon/Mercy: Helping Adults Steer Clear of the Emergency Room
Adults who are eligible for Medicaid due to a chronic illness or disability typically suffer from numerous conditions and often have complex multiple diagnoses, i.e., behavioral health problems linked with physical issues. Many of these adults use hospital emergency rooms as their main source of medical care. The result is deleterious for the patient and the public-at-large: health problems exacerbate when timely care is not provided, emergency rooms get backed up with non-emergent care, and the cost to the health plan and the health care system is substantial compared to the cost of routine preventive care.
Through participation in a Best Clinical and Administrative Practices pilot project, Horizon/Mercy, a Medicaid health plan in New Jersey, sought to use integrated social case management to reduce emergency room admissions. The plan identified individuals who frequently visited the emergency room and reached out to help them identify barriers to seeking primary care and address their health care needs more effectively. Horizon Mercy also stationed a social case manager in the emergency room of six high-volume hospitals to meet with members and provide education on the spot. The social worker arranged for transportation, follow-up appointments to a primary care provider, necessary durable medical equipment, and/or home health care visits.
"One of the things we realize is that people don't get up and say "I'm going to be a bad person: I'm going to be noncompliant,'" says Phil Bonaparte, MD, Medical Director, Horizon/Mercy. "They have their own issues, they have significant problems: physical, social, financial, as simple as having a place to stay -- having somebody who appears to care makes a huge difference."
Horizon/Mercy's pilot was hugely successful: within three months, Horizon/Mercy was able to decrease inpatient length of stay by 79 percent, decrease emergency room usage by 27 percent, increase primary care visits by 31 percent, and home health care visits by 336 percent. The plan is looking to expand the program to more hospitals in New Jersey and has made the pilot program a permanent part of its quality improvement efforts.
Contacts: Phil Bonaparte, MD, Medical Director, Horizon/Mercy, 609.538.0700, ext. 5186; Pam Persichilli, Director of Clinical Operations, Horizon/Mercy, 800.682.9094, ext. 5193; Member (identified through Pam Persichilli)
Johns Hopkins HealthCare: Using Phone Calls to Track Health Status
In the far reaches of rural Maryland, Johns Hopkins HealthCare found it extremely difficult to provide routine care for members with chronic illnesses and disabilities. Thirty-one percent of the plan's total population (117,000) reside not in metropolitan Baltimore, but in the rural areas of Maryland. Inpatient and emergency room admissions and costs for this population were high while use of primary care and specialty providers was low. Through Best Clinical and Administrative Practices, the plan piloted a TeleWatch program for rural-based members with chronic heart disease and/or diabetes to improve their access to appropriate and timely care.
The 50 patients enrolled in the pilot program received training from a nurse case manager on how to do basic monitoring at home (e.g., blood pressure, glucose levels, weight) and use the TeleWatch system to report health status on a daily or weekly basis. All clinical alerts are responded to by the nurse and may generate a call or visit to the patient, contact with the primary care provider, or continued monitoring. Patients who do not call in to the system are called or receive a home visit. Patient self-reported and other data (e.g., pharmacy reports, lab data, hospital and clinic records) are sent monthly by the health plan to the primary care provider.
Within three months, the results are promising. Patient satisfaction with health care increased, emergency room visits decreased, and overall cost of care has been reduced by more than $5,000 per member annually. One patient Joe*, a 42-year-old former truck driver who lives on Maryland's Eastern Shore, has Type II diabetes, diabetic neuropathy, restrictive lung disease, pericardial effusions, and morbid obesity. Joe had two inpatient medical admissions the month prior to enrolling. He had never had a blood glucose meter even though he was diabetic with significant neuropathy. Johns Hopkins Healthcare provided the monitor and training on how to use the equipment and helped him set health goals and locate a new primary care provider. He now sees a new provider regularly, and although he does not have a phone in his own home, he uses a friend's phone to call TeleWatch daily. Calling TeleWatch has helped Joe avert crisis episodes and stay out of the hospital; his nurse reports that he has made significant progress clinically.
Contacts: Sheldon Gottlieb, MD, Medical Director, Johns Hopkins Healthcare, 410.550.7036; Lauri Russell, Disease Management Director, Johns Hopkins Healthcare, 410.424.4694; Member (identified through Lauri Russell)
Programs for Children with Special Health Needs
Medically Fragile Children's Program: Building Stronger Families and Systems of Care
Terrell, age 15, nearly lost his life when a car hit him two years ago. "They told me there was a 50-50 chance that he wouldn't make it. He wasn't able to talk. When we first got to Medically Fragile, there were doubts...in my heart... that he would never walk again," says Terrell's mother, LaWanda. "He couldn't walk down the hallway or stand up and brush his teeth. But now, he can do all that, thanks to Medically Fragile."
South Carolina's Medically Fragile Children's Program (MFCP) continues to win acclaim from families and state officials who declare the program improves patient health and saves the state money. MFCP, originally established to provide a medical home for the state's foster children with special needs, now provides special care to all children with chronic illnesses and disabilities who are Medicaid eligible and up to 21 years of age.
Prior to the program, more dollars went to emergency care and hospitalizations. Under MFCP, those dollars are targeted to better meet the child's special needs. MFCP, a unique managed care program developed by South Carolina Medicaid and Palmetto Richland Hospital, functions in its own day health resource center at Palmetto Health facilities. Accessible 24 hours a day, 365 days a year, the MFCP provides participants with primary care, nursing care, therapies, counseling, durable medical equipment, medications, transportation, respite, and other essential services. Pat Votava, MFCP's director, is eager to share the experience of MFCP. "People are amazed to learn that we can do so much to change these children's lives and save $10,000 a year per child."
Contacts: Pat Votava, MFCP Director, 803.434.4467; Parent of child (identified through Pat Votava)
Lovelace Community Health Plan: Helping Children
with Special Needs through Family Involvement
Providing appropriate care for children with special health needs is an overwhelming challenge for many Medicaid health plans. Children with special health care needs -- approximately 13.6% of the population -- have chronic physical, developmental, behavioral or emotional conditions. Their diagnoses vary substantially as do their day-to-day requirements, and medical and psycho-social needs. But the common element is they all require extensive health and related services.
Keeping parents not only involved in care, but partners in care is a key way to help ensure that children receive the services they need. Lovelace Community Health Plan in New Mexico developed a series of consumer advisory boards across the state to uncover the barriers that parents face in helping their children receive proper care. In the vast "frontier" corners of the state, one of the key issues revealed by parents was simply access: access to providers without having to drive three or more hours. Through parent suggestions, Lovelace Health Plan is now contracting with physician assistants in New Mexico, as well as providers across the border in Arizona, to provide care to children with special needs.
"Simply listening to consumers in our advisory boards has helped us to rethink our programs to respond to kids and their families more effectively. Caring for a child with special needs is never going to be easy, but through the advisory boards we've found a way to bring parents to the table and bring a stronger voice to how to improve the quality of their children's care," says Denita Richards, Manager of Prevention and Wellness, Lovelace Community Health Plan.
Contacts: Jeanette Velarde, MD, Medical Director, Lovelace Health Plan, 505.232.1770; Denita Richards, Manager of Prevention and Wellness, Lovelace, 505.232.2700, ext. 2202; Parent of child (identified through Denita Richards)
Perfect Care for Everyone
California Asthma Collaborative: A Simple Revolution in Caring for Kids with Asthma
Asthma is the most common admitting diagnosis for low-income children in emergency rooms across the country. Although a highly treatable disease, it often goes untreated until it reaches a crisis requiring emergency care. For the child with asthma and family members who visit the emergency room regularly, asthma provides major disruptions to daily life. Although nationally recognized guidelines on treating and preventing asthma are available, implementing them effectively is a challenge for Medicaid health plans.
The Center for Health Care Strategies has worked with numerous Medicaid health plans nationally to improve the quality of care for children with asthma. From Brooklyn, New York, to Kansas City, Missouri,Q12 to Suisun, California, Medicaid health plans have helped families to create asthma care plans, use nebulizers effectively, and seek treatment when needed. Providers have received routine updates on children who are using too many rescue medications or are frequently visiting emergency rooms due to asthma episodes as well as training to implement evidence-based clinical guidelines more effectively.
With its California Asthma Collaborative, CHCS is taking lessons learned from individual Medicaid health plans to improve asthma care, for children and adults, across an entire state. The collaborative is working with Medi-Cal officials, managed care health plans, providers, and consumer groups to develop and implement clinical and administrative practices to improve asthma care for Medi-Cal enrollees. Fifteen teams have two major goals: establishing practices that improve clinical quality for enrollees with asthma, and maximizing limited resources by coordinating interventions and sharing information across stakeholder groups.
Team efforts are honing in on asthma quality improvement from all angles to develop an integrated approach to asthma management that involves the consumer, provider, health plan, and appropriate community services. Teams are standardizing the use of asthma action plans across provider networks and collaborating to create uniform provider training. High-volume practices are being targeted for practice-site improvements and patient education training. Teams from Alameda Alliance and Inland Empire Health Plan are identifying children 12 and under who visited the emergency due to an asthma episode for patient education as well as outreach to their providers.
This innovative effort is driving unprecedented partnerships among health plans that traditionally have not collaborated on improving health care quality. Best practices from this focused asthma quality initiative will be shared with the remaining Medicaid plans in California to ultimately increase the quality of asthma care throughout the state.
Contacts: Brad Gilbert, MD, Medical Director, Inland Empire Health Plan, 909.890.0200; Parent of a child who had frequented the ER for asthma care prior to the pilot (identified through Dr. Gilbert); Michael Lenoir, MD, Private Practice, Provider on the Alameda Alliance team, 707.863.4261; David Nunez, MD, Chief, CA Asthma Public Health Initiative, 916.445.5263
* Name changed for anonymity.
