Texas Health and Human Services
Commission
Medicaid Disease Management Program OverviewMedicaid Disease Management Program...
Agenda
Medicaid DM Program History
DM Program Overview
Opportunities for Collaboration with
Community Health Centers
Legislative Mandate
The Texas 78th
Legislative Session (2003)
mandated State agencies to focus on the
healthcare needs of ...
State RFP for Medicaid FFS DM Program
Program GoalsProgram Goals
Improve health statusImprove health status
Increase adher...
Why Disease Management?
Clinic visitClinic visit NextNext
Clinic visitClinic visit
Treatment PlanTreatment Plan
1-12 month...
State RFP for Medicaid FFS DM Program
Program ObjectivesProgram Objectives
Improve continuity of careImprove continuity of...
DM Vendor Selection
Multiple bidders summer ’03 for 1/04 awardMultiple bidders summer ’03 for 1/04 award
Initial plan to a...
McKesson Health Solutions Profile
Six care centersSix care centers
4 in Mainland USA, 1 in Puerto Rico, 1 in Westlake TX
E...
Heart Failure ProgramHeart Failure ProgramHeart Failure ProgramHeart Failure Program
McKesson DM Program Results
Diabetes ...
Economic Impact
 Behavior changes lead to improvements inBehavior changes lead to improvements in
compliance, functional ...
The Texas Medicaid
Enhanced Care Program
Disease ManagementDisease Management
Care CoordinationCare Coordination
24/7 Tria...
Who is eligible to participate?
Eligible Fee-For-Service Medicaid
clients with asthma, diabetes, heart
failure, CAD and CO...
Identification of Program Enrollees
State DataState Data
ClaimsClaimsEligibilityEligibility ProvidersProviders
Client-Clie...
DM Services Support Pts Between Office Visits
24 x 724 x 7
nursenurse
triagetriage
serviceservice
ProactiveProactive
Outbo...
Primary Care
60% of visits are for information
and reassurance rather than
treatment (7) Our triage service
directs 40% to...
A recent ground breaking RCT just competed by the Geffen School of Medicine at UCLA
compared McKesson nurse triage of symp...
Tiered Interventions based on risk
Proprietary Risk StratificationProprietary Risk Stratification
STABLESTABLE
(Level 1)(L...
DM Program Launch – November 2004
Physician
Communications
PatientPatient
CommunicationsCommunications
DM Program IntroDM...
Physician Communications
Introductory Mailing
Cover letter with listCover letter with list
of physician’sof physician’s
p...
Introductory Materials Provided to All
clients Eligible to Participate
Personalized letterPersonalized letter
44thth
grade...
Personalized Patient Education
Assess: Maslow's hierarchy of needs, Prochaska/
readiness to change, clinical, functional,...
Personalized Support: Action Plans
Developed for All Program Enrollees
 Prevention
 Education
 Screening and testing
 ...
Personalized Support: Special Needs
Coordination and Physician Alerts
 Compliance and adherence
 Three Severity Levels
...
How do Providers Benefit?
Improvement in patient self-mgmt skills:Improvement in patient self-mgmt skills:
 Better adhere...
Program Launch (first 90 days)Program Launch (first 90 days)
 Orient CHC staffOrient CHC staff to new programto new progr...
Opportunities for Collaboration
with Texas Community Health Centers
Post Launch PeriodPost Launch Period
Coordinate resour...
Opportunities for Collaboration
with Texas Community Health Centers
Longer Term GoalsLonger Term Goals
Demonstrate value o...
Program Contact Information
In-State Program Manager
Barbara Ramsey – (866) 645-0312
HHSC Senior Policy Analyst
Geri Wille...
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Texas Health and Human Services Commission

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  • People with chronic illness are frequently overwhelmed. Compliance, anxiety, depression and inappropriate access to care frequently occur.
    This program supports the patient physician relationship. The nurses help bridge the gap between physician office visits.
    This program proactively identifies and manages patient high risk behavior which positively impacts physician practices.
  • These are ranges to show what we have been seeing across all diseases
  • Eligible clients includes all beneficiaries with the diseases listed above. Beneficiaries that reside in nursing homes, skilled nursing homes, are dually eligible, etc are not eligible to participate in the program. Note that in order to be eligible for the hypertension program, you must have heart failure, COPD or CAD.
  • We will analysis your data, utilizing claims and pharma
    Also will use Triage (CareEnhance 360) and referrals from pharmacists, case managers, and providers for member identification.
    From this data we will be ale to obtain a list of members who have the condition
  • Third party evidence supports the 360 opportunity
    The numbers support that a new approach is required – because historical approaches are no longer working . The numbers come from numerous, credible third party sources
    We believe the primary reason these types of statistics exist are due to the fact that past and present medical management solutions have not been able to proactively reach and engage members to arm them with the right information and tools to foster appropriate decision making and behavior at the time of need.
    Read each point and acknowledge sources if necessary
  • To introduce our model at a high level before we review program detail:
    Members are identified through diagnostic, pharmacy or lab claims, member newsletters and mailings.
    Members and physicians are encouraged to call in, send a BRC or contact us On-Line to enroll into the program.
    We proactively contact at risk and high risk members.
    On-Demand and proactive outbound services are administered supported by case management and physician alerts to ensure proactive intervention, home healthcare and support for high risk patients.
  • Remember the physician communication goes out first before the program starts, this will contain a list identified members that are being treated by that PCP
    McKesson will go with a client representative to visit with key physicians or groups to explain he program
    Patient communication: age level 6 and 9the grade, English and Spanish, we can do other languages but it will be an added cost.
    All communications, letter and scripts will be customized for each client. 2% to 5% will self enroll the rest will be called in our outbound program
    Important to have accurate phone numbers to have good enrollment
    Our nurses make 5 attempts over 3 wks, then a letter would go out to the member letting them know that we are trying to reach them about a special program. Member will be placed back in the queue for another call after the letter is sent.
  • We share the list of patient identified through claims data so that they can review the list and see if they agree with the diagnosis and the selection
    We share the guidelines to let them know we are following the national evidenced based standards
    We also share with them the program overview so that they can see in detail how we can help them educate and work with their patients
  • Take notes from Kathy’ presentation
  • McKesson made a clinical choice to utilize action plans for all conditions not just asthma
    We found that patient that utilized action plans had better outcomes
    This tools improve the patient educational level by giving them a guide to remind them of preventative measures and medications, diet exercise etc
    This document is sent to the patient, they are instructed to take it with them on their next MD visit and have the doctor review it with them.
    This give the MD and the patient and opportunity to discuss the patients condition and items of importance.
    This document is then shared with the nurse on the next call and this allows all parties to be working for m the same document.
    ( the doctor, the patient and the nurse)
    This is a highly affective tool.
  • Clinical alerts our McKesson’s way of communicating with the members physician on issues of status change, decompensation or pending risk
    They are set up in three levels of severity and the document is generated by the clinical system. Only level three alerts will get a direct call from the DM nurse into the office to speak with the MD or staff member. All levels will be faxed but before the fax is sent a call will be made to verify that the fax number is correct or that someone is there to receive it.
    Coordination with our Medicaid Special Needs Coordinator is vital to the success of any program therefore we communicate with them on an a regular bases through a clinical alert document. By doing this we can identify areas of concern and can decide how to handle the situation and provide beneficiaries with help in either finding a physician, pharmacy, etc.
  • Texas Health and Human Services Commission

    1. 1. Texas Health and Human Services Commission Medicaid Disease Management Program OverviewMedicaid Disease Management Program Overview Texas Association of Community Health Centers Annual MeetingTexas Association of Community Health Centers Annual Meeting October 26, 2004October 26, 2004 Maureen Mangotich MD, MPHMaureen Mangotich MD, MPH Medical Director, Provider and Community OutreachMedical Director, Provider and Community Outreach McKesson Health SolutionsMcKesson Health Solutions
    2. 2. Agenda Medicaid DM Program History DM Program Overview Opportunities for Collaboration with Community Health Centers
    3. 3. Legislative Mandate The Texas 78th Legislative Session (2003) mandated State agencies to focus on the healthcare needs of the underserved and needy The legislation mandates measurable financial and clinical results, and proactively reduced budgets
    4. 4. State RFP for Medicaid FFS DM Program Program GoalsProgram Goals Improve health statusImprove health status Increase adherence to national evidence based guidelines Reduce overall medical costsReduce overall medical costs Savings expectations – a minimum of 5% of total expenditures for the eligible population served
    5. 5. Why Disease Management? Clinic visitClinic visit NextNext Clinic visitClinic visit Treatment PlanTreatment Plan 1-12 months Late Rx Refill Acute Sx – ER visit Avoidable IP admit
    6. 6. State RFP for Medicaid FFS DM Program Program ObjectivesProgram Objectives Improve continuity of careImprove continuity of care Increase access to preventive careIncrease access to preventive care Enhance clients’ relationship with their primaryEnhance clients’ relationship with their primary caregiver and other providerscaregiver and other providers Improve coordination and collaboration amongImprove coordination and collaboration among healthcare providers and other communityhealthcare providers and other community resourcesresources Reduce unnecessary hospital admits, totalReduce unnecessary hospital admits, total hospital days, ER visitshospital days, ER visits
    7. 7. DM Vendor Selection Multiple bidders summer ’03 for 1/04 awardMultiple bidders summer ’03 for 1/04 award Initial plan to award South and North separatelyInitial plan to award South and North separately 2 Finalists 7/1/04 McKesson chosen for entire state7/1/04 McKesson chosen for entire state Major reasons: - Guaranteed savings - Risk contract – 100% of fees - 60 day implementation
    8. 8. McKesson Health Solutions Profile Six care centersSix care centers 4 in Mainland USA, 1 in Puerto Rico, 1 in Westlake TX Employ ~ 400 nurses in N. America Nurse Advice Line (Triage Services)Nurse Advice Line (Triage Services) ~ 25MM covered lives in Triage Disease Management ProgramsDisease Management Programs Asthma, COPD, Diabetes, CAD, Heart Failure 80 DM clients (MCO, Medicaid, Employers, Pharma 8 Medicaid Contracts: Colorado, Florida, Mississippi, Montana, New Hampshire New Jersey, Oregon, Puerto Rico, Washington Accredited by JCAHO, NCQA, URAC
    9. 9. Heart Failure ProgramHeart Failure ProgramHeart Failure ProgramHeart Failure Program McKesson DM Program Results Diabetes ProgramDiabetes ProgramDiabetes ProgramDiabetes Program Asthma ProgramAsthma ProgramAsthma ProgramAsthma Program •89% increase in ACE-inhibitor prescriptions •24% increase in annual flu vaccinations •114% increase in pts weighing themselves daily •155% increase in pts keeping a weight record •44% increase in pts following a low-salt diet •33% increase in pts who do SMBG monitoring •70% increase in aspirin use •22% reporting lower blood glucose levels •20% show improved functional status •91% increase in patients with action plans •85% in asthmatics who own peak flow meters •34% increase in asthmatics using spacers
    10. 10. Economic Impact  Behavior changes lead to improvements inBehavior changes lead to improvements in compliance, functional status, symptom controlcompliance, functional status, symptom control,, andand reduced service utilizationreduced service utilization Claims-based studiesClaims-based studies show:show: Range:Range: • Reduction in inpatient hospitalizationsReduction in inpatient hospitalizations • Reduction in ED visitsReduction in ED visits • Gross savings per person per annumGross savings per person per annum • Return on investmentReturn on investment (Dollars saved for every dollar spent)(Dollars saved for every dollar spent) 15% – 53%15% – 53% 5% – 31%5% – 31% $279 – $2,560$279 – $2,560 $1.55 – >$3.00$1.55 – >$3.00
    11. 11. The Texas Medicaid Enhanced Care Program Disease ManagementDisease Management Care CoordinationCare Coordination 24/7 Triage Services24/7 Triage Services
    12. 12. Who is eligible to participate? Eligible Fee-For-Service Medicaid clients with asthma, diabetes, heart failure, CAD and COPD Opt Out Program Clients are automatically enrolled unless they choose not to participate
    13. 13. Identification of Program Enrollees State DataState Data ClaimsClaimsEligibilityEligibility ProvidersProviders Client-Client- ProviderProvider LinksLinks TargetTarget ClientsClients Medical Home
    14. 14. DM Services Support Pts Between Office Visits 24 x 724 x 7 nursenurse triagetriage serviceservice ProactiveProactive OutboundOutbound Nurse CallsNurse Calls CommunityCommunity SupportSupport ServicesServices PromotoraPromotora outreach/outreach/ enrollmentenrollment contactscontacts Face to faceFace to face nursenurse contactscontacts ProviderProvider mailing withmailing with patient listpatient list CareCare coordinationcoordination servicesservices Pt mailings:Pt mailings: educationaleducational materials,materials, reports,reports, remindersreminders AudiohealthAudiohealth LibraryLibrary (English(English andand Spanish)Spanish) Coordinate Triage &Navigate R.N. M.D.Patient MD Reports:MD Reports: ClinicalClinical alerts, ptalerts, pt updatesupdates
    15. 15. Primary Care 60% of visits are for information and reassurance rather than treatment (7) Our triage service directs 40% to home/self care ER Care 53% of visits are not urgent; (3) Our triage service directs more than 86% away from ER and Urgent Care facilities Select High Cost Surgical Procedures/Bed Days Significant variation of surgical treatments for common diseases (8) Chronic Illness Chronic illnesses drive 60% of the nations medical care costs (1) 1 out of 3 callers have a chronic /catastrophic or mental health condition – 75% elect to enroll (2) Sources (1) The Robert Wood Johnson Foundation, Annual Report, 2000 (2) Internal McK Research, 2001 and 360 pilot results, March, 2002 (3) National emergency care utilization report -NCHS, 2001 (4) Harris Interactive and Harvard School of Public Health Research Study, 2000 (5) Cyber Dialogue and Deloitte & Touche, Strategy and E-Health, 2001 (6) Health Affairs Article, 2001 and Agency for Healthcare Research and Quality (7) Modern HealthCare, June, 2000; source: Agency for Healthcare Research and Quality (8) The Dartmouth Atlas, 2000 Evidence supporting nurse triage Avoidable Admissions 1 out of every 9 admissions is avoidable with improved access to care (6) Member Participation In Medical Decisions 90% of consumers want greater participation in decision making. (4) 50 mm online health users (5)
    16. 16. A recent ground breaking RCT just competed by the Geffen School of Medicine at UCLA compared McKesson nurse triage of symptoms to a panel of Board Certified Pediatric Emergency Medicine Specialists from a major Academic Institution … the result no significant differences in care recommendations Randomized control study N = 3,193 medical advice pediatric calls Study period was 11 months Referred to 3 categories ED/Urgent Care, Office Care, Self Care Callers were randomly routed to either a physician or nurse. The caller was then triaged and the result were recorded. There was no significant difference in where the physician recommended the caller seek care vs where the nurse recommended the caller seek care 0 10 20 30 40 50 60 70 80 ED/Urgent Care Office Care Self Care Physician Nurse 11.4% 10.7% 19.0% 18.7% 69.6% 70.6% Proof that our triage clinical content and nurse quality management processes are working….
    17. 17. Tiered Interventions based on risk Proprietary Risk StratificationProprietary Risk Stratification STABLESTABLE (Level 1)(Level 1) Audio health Library Educational Mailings 24x7 nurse line Provider AlertsProvider Alerts AT RISK (Level 2) Proactive callsProactive calls Level 2 services Case mgmt referralsCase mgmt referrals HIGH RISK (Level 3) In-person visitsIn-person visits Home MonitoringHome Monitoring DevicesDevices Level 1 services Level 1 services
    18. 18. DM Program Launch – November 2004 Physician Communications PatientPatient CommunicationsCommunications DM Program IntroDM Program Intro Pt List, GuidelinePt List, Guideline info. Programinfo. Program brochurebrochure DM Welcome letterDM Welcome letter Toll free numberToll free number Business reply cardBusiness reply card Calling card incentiveCalling card incentive Enrollment ContactsEnrollment Contacts
    19. 19. Physician Communications Introductory Mailing Cover letter with listCover letter with list of physician’sof physician’s patients eligible forpatients eligible for enrollmentenrollment Program InformationProgram Information Clinical guidelinesClinical guidelines Stepped Inserts:Stepped Inserts:  Program benefits to pts, provider  FAQs
    20. 20. Introductory Materials Provided to All clients Eligible to Participate Personalized letterPersonalized letter 44thth grade reading levelgrade reading level Magnet with Toll FreeMagnet with Toll Free numbernumber Easy to read educationalEasy to read educational pamphletpamphlet Mail or hand deliveredMail or hand delivered
    21. 21. Personalized Patient Education Assess: Maslow's hierarchy of needs, Prochaska/ readiness to change, clinical, functional, utilization, knowledge level, risk metrics and QOL Teach: Condition knowledge, self-management skills, medication compliance, prevention, proactive management Reinforce improvement: Action plans, monitoring, 24/7 nurse advice line, health counseling and fulfillment Modify Goals: Re-assessment 6 and 12 months, re- education, monitoring, etc.
    22. 22. Personalized Support: Action Plans Developed for All Program Enrollees  Prevention  Education  Screening and testing  Medication reminders Warning signs and symptoms  Provider partnering
    23. 23. Personalized Support: Special Needs Coordination and Physician Alerts  Compliance and adherence  Three Severity Levels Level 3 alerts faxed to office/clinic after nurse call  Access concerns  Utilization issues  Financial issues
    24. 24. How do Providers Benefit? Improvement in patient self-mgmt skills:Improvement in patient self-mgmt skills:  Better adherence to medical regimen  Earlier recognition of decompensation and PCP contact for urgent evaluation  Improved continuity of careImproved continuity of care  Reduced “no-shows” for office appts  Fewer after-hours calls  Fewer calls to nurse staff during office hours
    25. 25. Program Launch (first 90 days)Program Launch (first 90 days)  Orient CHC staffOrient CHC staff to new programto new program Review lists of identified DM enrolleesReview lists of identified DM enrollees  Validate identified cases and provider linkages  Recommend appropriate level of DM services/support  Identify CHC clients not currently on DM program rolls who might be eligible Recommend CHC Representative to serve onRecommend CHC Representative to serve on Statewide Provider Advisory BoardStatewide Provider Advisory Board Opportunities for Collaboration with Texas Community Health Centers
    26. 26. Opportunities for Collaboration with Texas Community Health Centers Post Launch PeriodPost Launch Period Coordinate resources to optimizeCoordinate resources to optimize appropriate access to primary careappropriate access to primary care servicesservices Promote 24x7 telephone triage service to reduce office/ER visits for c/o appropriate for self-care Expedited appt access for DM managed clients with urgent clinical issues
    27. 27. Opportunities for Collaboration with Texas Community Health Centers Longer Term GoalsLonger Term Goals Demonstrate value of collaborative careDemonstrate value of collaborative care Number of similarities between DM program and CHCs in mission, approach, services offered Share tool kitsShare tool kits Educate clinicians in populationEducate clinicians in population management tools, techniquesmanagement tools, techniques
    28. 28. Program Contact Information In-State Program Manager Barbara Ramsey – (866) 645-0312 HHSC Senior Policy Analyst Geri Willems– (512) 491-1460

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