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Care managers have more resources at their disposal in new Medicaid effort in Florida

Two years after deciding to discontinue what had been the state’s largest Medicaid DM program to date, Florida’s Agency for Health Care Administration (AHCA) has elected to try again. The agency is working with the same vendor that implemented the earlier program on an expanded DM effort that is expected to provide education and coaching support to more than 90,000 Medicaid beneficiaries with chronic disease.

Beginning in January, Pfizer Health Solutions (PHS), the New York City–based care management subsidiary of Pfizer, Inc., began implementing Healthier Florida. The program has many similarities to its predecessor, Florida: A Healthy State, but administrators point out that, in addition to including some new disease states, program components have been enhanced to put more services at the disposal of nurse care managers and the patients they serve.

Also, as with the earlier effort, Broomfield, CO–based McKesson Health Solutions (MHS) is playing a prominent role in the approach—this time assembling all of the multidisciplinary teams that will work within various state regions to meet the care needs of enrolled beneficiaries.

Pfizer proposal offers security

Even after Florida: A Healthy State formally ended in 2005, both Pfizer and McKesson continued to work in the state, providing DM services to Medicaid recipients. In the meantime, AHCA prepared an invitation to negotiate, which attracted bids from several DM vendors interested in launching the new program. Evaluators considered many factors when examining the various proposals, but Pfizer’s earlier work in the state had little to do with winning the new contract, says Sybil Richard, COO of Florida’s Medicaid program. AHCA asked for bids on four specific DM programs—CHF, diabetes, hypertension, and asthma—with the option to include another three programs focused on sickle cell anemia, renal disease, and chronic obstructive pulmonary disease, says Richard.

“One of the things that was attractive in Pfizer’s program was that they didn’t just bid on the initial four DM programs; they bid on [all seven programs], and although our comprehensive DM program might have been based on the four programs that were already operational in the state, their proposal gave us some security that we could move forward with new programs,” Richard says. She adds the state never intended to discontinue offering DM services, but rather it wanted to devise a different funding stream for these services, which it has done with the new contract. Additionally, AHCA awarded the new program to Pfizer based on a competitive process that was not in place when it awarded the earlier contract.

More resources are at hand

Under Healthier Florida, nurse care managers will still be the primary points of contact for beneficiaries enrolled in the program, but Pfizer is applying a much more multidisciplinary approach this time around, according to Donna Licthi, RN, senior director and team leader for state and international initiatives at PHS.

“Where we had care managers and diabetes specialists [before], we now have care managers, behavioral health specialists, pharmacists, social workers, and community health workers,” she says, noting that Pfizer discovered that the care managers needed to have a deeper breadth of professional help.

“We realized that these patients have multiple needs, and there is never really one specific thing that is driving the problems,” says Licthi. “When you have someone who has multiple comorbid conditions and a lot of social problems, you can’t really focus in on a disease when you have so many social issues occurring.”

There is, in fact, a large mental health component involved to caring for this population, says Diane Creal, RN, CNS, the director of program launches at MHS. “We are fortunate to have individuals who focus specifically on some of those sickest patients who have mental health issues, so it is a very comprehensive, holistic model,” she says.

Further, whereas nurse care managers involved with the earlier Pfizer program devoted some of their time to community outreach, the new effort incorporates community health workers into the care teams so they can focus all of their efforts on community-based work.

“These are people who are familiar with their own community, and many times they are familiar with the particular diseases [affecting patients],” says Licthi, noting that this type of cultural familiarity and understanding elicits trust from recipients.

The community health workers fulfill some patient education functions, including setting up group classes for recipients with similar diseases. In addition, they are available to the nurse care manager for any number of tasks.“In the past, if the nurse had a patient whom she suspected could not read . . . and there was a medication compliance issue, she would have to do the best she could with that,” says Creal. “Now, however, she can deploy her local community health worker to the patient’s home to [evaluate the issue].” The extra support, not only from the community health workers, but also from the entire team, gives the nurse more control over the outcome of the patient, she says.

Contact is a challenge

The state and PHS have developed multiple ways for patients to be referred into the program. However, the state identifies most potential candidates initially through claims analysis. It then passes on this information to PHS for further analysis and stratification. The critical factors considered at this stage are specific diagnoses, utilization history, and time of diagnosis, explains Licthi. “Based on this stratification, the nurses will know how to outreach to the patient, and they will also know who their PCPs are,” she says.

In this population, it can be very difficult to make contact with patients. Consequently, PHS is employing several communications strategies, including phone calls, mail, physician referrals, and in-person contact. “You have to use many different vehicles,” Licthi says. “Sometimes we use the Medicaid offices as well.”

Once a care manager has made contact with a recipient, and the recipient has agreed to participate in the program, it may take several phone calls to get through the initial assessment. “The nurse has to make some determinations about how to start,” says Licthi. “Some of the things they need to capture include verifying the last time the recipient was in the hospital, who their PCP is, what medications they are taking and how frequently, what symptoms they have, and what they know about their illness.”

When recipients have a PCP, the care managers will also make contact with the provider to get his or her input on the recipient. However, in cases in which there is no PCP, one of the first goals of the care manager will be to establish a medical home for that recipient.

“It is important to have someone they can go to a regular basis,” says Licthi. “Obviously, we want to avoid ER visits, so really getting someone started on a program with a PCP who can follow them, as well as any specialty physicians that they need, [is critical].”

As the relationship between the care manager and patient develops, the nurse will begin to understand what motivates the patient, and he or she can then target those issues where there is the most potential for improvement. For example, in the case of a patient who has diabetes, weighs 250 lbs, is a smoker, and cannot afford the cab fee to get to a physician’s office visit, Licthi explains that the nurse will ask probing questions to home in on areas in which the recipient is ready to make some changes.

“The care manager really tries to be a friendly coach, a mentor, and a cheerleader for the things that are important to that person,” she says. “So while the recipient might not be ready to talk about smoking cessation, she might be willing to get out and walk around the block a few times each week. That might be the beginning of an exercise program, so the nurse will establish some goals around that.” During the next call, the nurse will determine whether the recipient made progress with those initial goals, and then he or she will proceed from there, adds Licthi.

Everything is local

Creal, who has been responsible for putting personnel in place to implement McKesson’s part of the model, emphasizes that it was important to build the multidisciplinary care teams from the regions they will be serving. “If you want to do this right, you’ve got to do it locally,” she says. “What is happening in the northern part of the state may be very different than what is happening or working in the southern part of the state. And now I have teams specifically focusing on those areas so that we can get that feedback.”

Ramping up for the program has been a huge endeavor, requiring months of touring the state, interviewing, and hiring. However, Creal points out that there was a wide pool of applicants interested in participating.

“This is unique, and as I talked to social workers, pharmacists, and dietitians, they found it to be a very different career path,” she says, adding that the model had particular appeal to care managers. “This is truly primary care nursing where you have those resources available, and you can pull them in, so it is good for the patient, the nurse, and the team.”

How well the model will work in terms of producing good clinical and financial results remains to be seen, but the idea of linking the many facets of care had strong appeal to the state.

“It does not help the patient to have systems of care where the providers aren’t talking to each other,” says Richard.

“We are all about integrative care,” she adds. “That is what our Medicaid reform model is [focused on]: bringing all of the pieces together in the treatment of whole health—both physical and behavioral healthcare from one system of care.”