Montana Health Improvement Program: New Roles for FQHCs in State Delivery System Reform Janice Gomersall, MD, FAAFP Medica...
What we will cover <ul><ul><li>Care Management  vs  Disease Management </li></ul></ul><ul><ul><li>Previous Program in Mont...
Previously…. <ul><li>Montana Medicaid used a Disease Management Program administered by an out of state vendor </li></ul><...
Development  of Current HIP <ul><li>Realization what made patients high risk </li></ul><ul><li>Development of RFP </li></u...
Health Improvement Program  Introduction <ul><li>Predictive Modeling Software identifies high risk patients </li></ul><ul>...
Disease Management vs.   Care Management <ul><li>Disease Management deals with specific  diseases , with the idea that if ...
New Health Improvement Program <ul><li>An enhancement to Montana’s current Primary Care Case Management Program (Passport)...
Service  Providers  for the New HIP <ul><li>Cornerstone :  enhancement of community-based comprehensive primary and preven...
Janice Gomersall
Northwest CHC Libby  Flathead CHC Kalispell  Partnership CHC Missoula  Cooperative Health Center Helena  Cascade CHC Great...
Services  Provided by Specially Trained Nurses and Health Coaches at FQHCs <ul><li>Health Assessment (initial and periodic...
INTERVENTION  for High Risk/ High Cost Patients <ul><li>Patients are identified through predictive modeling software. </li...
PREVENTION  for At risk Patients <ul><li>Patients may be identified and referred by primary care providers </li></ul><ul><...
Reporting of Data <ul><li>Patient assessments (SF-12) </li></ul><ul><li>Workload management </li></ul><ul><li>Time to eval...
<ul><li>COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM </li></ul><ul><li>Montana operates this program as an Enhance...
<ul><li>COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM (cont) </li></ul><ul><li>PMPM fee is considered a case manage...
Janice Gomersall
Some Reasons Why Health Centers Appreciate the Program <ul><li>Recognition (including financially) of what they already do...
Some Reasons Why Providers Appreciate the Program <ul><li>Providers can refer into the program </li></ul><ul><li>Provides ...
Lessons learned <ul><li>Include everything you need in the PMPM (including database and Medical Advisor) </li></ul><ul><li...
Summary <ul><li>Previous Program </li></ul><ul><li>Limited to 4 disease states </li></ul><ul><li>Focus on disease manageme...
For questions, (or to avoid a really bad time) please contact Wendy Sturn at (406) 444-1292 or  [email_address] or Janice ...
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Montana Health Improvement Program: New Roles for FQHCs in State Delivery System Reform

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  • Rattlesnake
  • Flathead Lake looking at Glacier
  • Predictive modeling software is purchased by the state.
  • All sites have access, learn how to profile, sort through care opportunities; phone training for everyone who has been hired, plus end user training sessions through webinars (i.e. care managers)
  • Data collection was to cost $230,000 with a contract company; CMS did not consider it a benefit so would not match it 70/30; MT state would not let the cost go through at only 50/50 match. When Mck was contracted, the IT was part of the contract and the whole contract was matched 70/30. SF-12 could be administered at 3 months or 6 months depending on how long we expect pt to be in the program.
  • It is a subprogram of Passport; we separated out the advice line; just renamed from our DM program. Passport is a waiver program as it requires Native American participation; considered a ‘benefit’ so has to be an opt out program. No Caroline does a SPA (state plan), Idaho only does a telephonic/education program so is only matched 50/50.
  • Current program is $2.8 to 2.9 million/yr; previous program was $3.1 million/yr. Eventually will have 35 FTE care managers. 17 are RN, 1 NP (Poplar, WolfePoint School Health), rest are a combo of LPN, MSW, Health Educator
  • Flathead Lake
  • Montana Health Improvement Program: New Roles for FQHCs in State Delivery System Reform

    1. 1. Montana Health Improvement Program: New Roles for FQHCs in State Delivery System Reform Janice Gomersall, MD, FAAFP Medical Advisor, HIP, Montana Medicaid NASHP Conference October 4-6, 2010
    2. 2. What we will cover <ul><ul><li>Care Management vs Disease Management </li></ul></ul><ul><ul><li>Previous Program in Montana </li></ul></ul><ul><ul><li>Development of Montana Program </li></ul></ul><ul><ul><li>Using FQHCs to deliver the Care Coordination </li></ul></ul><ul><ul><li>Lessons learned </li></ul></ul><ul><ul><li>Relevance to health care delivery needs </li></ul></ul>Janice Gomersall
    3. 3. Previously…. <ul><li>Montana Medicaid used a Disease Management Program administered by an out of state vendor </li></ul><ul><li>Concentrated on managing four chronic diseases: Asthma, Diabetes, Heart Failure, and Chronic Pain </li></ul><ul><li>Used both telephonic and community based nurses to assess and manage patients, as well as targeted mailings </li></ul>Janice Gomersall
    4. 4. Development of Current HIP <ul><li>Realization what made patients high risk </li></ul><ul><li>Development of RFP </li></ul><ul><li>CMS negotiations </li></ul><ul><li>Outreach to CHC and Tribal Health Centers </li></ul><ul><li>Negotiations for full state coverage </li></ul><ul><li>In person meetings with Health Centers </li></ul><ul><li>Even a stimulus to develop reporting methodology from each site </li></ul>Janice Gomersall
    5. 5. Health Improvement Program Introduction <ul><li>Predictive Modeling Software identifies high risk patients </li></ul><ul><li>Care managers reach out to those identified patients to find out what is needed to lower their risk </li></ul><ul><li>Care managers, hired by CHC and Tribal Health Centers, work with the primary care providers to develop a care plan </li></ul><ul><li>Care is delivered via in person visits, telephonic, and care plans </li></ul><ul><li>Reporting of data </li></ul>Janice Gomersall
    6. 6. Disease Management vs. Care Management <ul><li>Disease Management deals with specific diseases , with the idea that if we control the specific disease in a patient we can control costs, complications, and have better outcomes </li></ul><ul><li>Care management deals with the specific patient , with the idea that patients who incur high costs and complications do so because of multiple medical, social, environmental factors which need to be controlled. </li></ul>Janice Gomersall
    7. 7. New Health Improvement Program <ul><li>An enhancement to Montana’s current Primary Care Case Management Program (Passport) that will provide: </li></ul><ul><li>Disease Management for high risk / high cost patients ( not limited to four disease states ) </li></ul><ul><li>and </li></ul><ul><li>Prevention efforts for patients at risk of developing chronic health conditions </li></ul><ul><li>Services provided by specially trained nurses, and health coaches, all certified in Chronic Care Professional Program </li></ul>Janice Gomersall
    8. 8. Service Providers for the New HIP <ul><li>Cornerstone : enhancement of community-based comprehensive primary and preventative health care. </li></ul><ul><li>Providers are Nurses and Health Coaches employed by Community and Tribal Health Centers who submitted proposals during the State’s procurement process. </li></ul><ul><li>All providers are CCP certified within 3 months of hire. </li></ul><ul><li>There are 14 centers covering 56 counties </li></ul>Janice Gomersall
    9. 9. Janice Gomersall
    10. 10. Northwest CHC Libby Flathead CHC Kalispell Partnership CHC Missoula Cooperative Health Center Helena Cascade CHC Great Falls Bullhook CHC Havre Butte CHC Community Health Partners – Livingston Sweet Medical Center Chinook Central Montana CHC Lewistown RiverStone CHC Billings Ashland CHC Custer Co. CHC Miles City Fort Peck Tribal Health Center Poplar
    11. 11. Services Provided by Specially Trained Nurses and Health Coaches at FQHCs <ul><li>Health Assessment (initial and periodic) </li></ul><ul><li>Ongoing clinical assessment (in person and telephonic) </li></ul><ul><li>Individualized treatment/action plan </li></ul><ul><li>Hospital pre-discharge planning and post-discharge visits </li></ul><ul><li>Self-management education </li></ul><ul><li>Group appointments </li></ul><ul><li>Tracking and documenting progress </li></ul><ul><li>Assistance with and referral to local resources such as social services, housing, food bank and other life issues </li></ul>Janice Gomersall
    12. 12. INTERVENTION for High Risk/ High Cost Patients <ul><li>Patients are identified through predictive modeling software. </li></ul><ul><li>Predictive modeling uses claims history and demographic information such as age and sex to calculate a risk score. </li></ul>Janice Gomersall
    13. 13. PREVENTION for At risk Patients <ul><li>Patients may be identified and referred by primary care providers </li></ul><ul><li>May include patients who have no claims that generate a high risk score or have not yet been diagnosed with an illness </li></ul>Janice Gomersall
    14. 14. Reporting of Data <ul><li>Patient assessments (SF-12) </li></ul><ul><li>Workload management </li></ul><ul><li>Time to evaluate, intervene, and follow-up </li></ul><ul><li>Patient satisfaction </li></ul><ul><li>Provider Satisfaction and knowledge </li></ul><ul><li>Main limitation is in resources for data collection, evaluation in an efficient manner </li></ul>Janice Gomersall
    15. 15. <ul><li>COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM </li></ul><ul><li>Montana operates this program as an Enhanced Primary Care Case Management Program under the authority of a 1915(b) Waiver </li></ul><ul><li>Approximately 70% of MT Medicaid members are eligible </li></ul><ul><li>A payment of $3.75 per member per month is made for every eligible member to the Health Center in the region the member resides </li></ul><ul><li>Members in the top 5% of risk scores are provided care management </li></ul><ul><li>Health Centers are paid for all members in their region regardless of who the member’s primary care provider is </li></ul>Janice Gomersall
    16. 16. <ul><li>COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM (cont) </li></ul><ul><li>PMPM fee is considered a case management fee and is matched at approximately 70/30 FMAP </li></ul><ul><li>Payment is made through the MMIS directly to each health center </li></ul><ul><li>Total cost of the program is approximately 8% less than the former contract with an out-of-state disease management organization </li></ul><ul><li>Direct Care Management staff went from 4.5 FTE under the old model to 27 FTE (eventually 35) </li></ul>Janice Gomersall
    17. 17. Janice Gomersall
    18. 18. Some Reasons Why Health Centers Appreciate the Program <ul><li>Recognition (including financially) of what they already do </li></ul><ul><li>Greater capacity to provide services </li></ul><ul><li>Coordination in accessing community services </li></ul><ul><li>Pipeline of MCD clients (including dental) </li></ul><ul><li>A stated mission in Montana PCA is to keep patients out of specialty care and hospitals. Care management is in line with this mission. </li></ul>Janice Gomersall
    19. 19. Some Reasons Why Providers Appreciate the Program <ul><li>Providers can refer into the program </li></ul><ul><li>Provides added service they often do not have staff nor time to perform </li></ul><ul><li>Small practices can take advantage of regionalized care managers </li></ul><ul><li>May add a component of medical home for their practice </li></ul><ul><li>They really don’t have to do anything extra </li></ul><ul><li>The delivery of care is from a local source, referring to local resources. </li></ul>Janice Gomersall
    20. 20. Lessons learned <ul><li>Include everything you need in the PMPM (including database and Medical Advisor) </li></ul><ul><li>Provide general Medicaid training for care managers (eligibility, systems) </li></ul><ul><li>Start working with FQHCs and CMS simultaneously and early </li></ul><ul><li>Develop guidance for program well before launch date </li></ul>Janice Gomersall
    21. 21. Summary <ul><li>Previous Program </li></ul><ul><li>Limited to 4 disease states </li></ul><ul><li>Focus on disease management </li></ul><ul><li>Out-of state vendor </li></ul><ul><li>Four community based RNs </li></ul><ul><li>New Program </li></ul><ul><li>Inclusive of any combination of chronic disease states </li></ul><ul><li>Disease management and prevention, care management </li></ul><ul><li>Local community-based providers </li></ul><ul><li>More than 25 Nurses and Health Coaches based in the communities </li></ul>Janice Gomersall
    22. 22. For questions, (or to avoid a really bad time) please contact Wendy Sturn at (406) 444-1292 or [email_address] or Janice Gomersall, MD at jgomers@bresnan.net Montana Medicaid Health Improvement Program Janice Gomersall

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