Missouri's Division of Medical Services is implementing a new program that attempts to leverage the power of new technology, community-based support, and providerfocused performance reports to dramatically transform its approach to caring for chronically ill Medicaid recipients. The state's chronic care improvement program (CCIP) is targeting a group that comprises only 20% of all Medicaid recipients in the state, but accounts for nearly 80% of the organization's costs. The state believes that better management of this population will not only improve the care of, and the quality of life for, chronically ill Medicaid recipients, but also deliver cost savings over the long term.
Silver Spring, MD-based APS Healthcare, which has been working closely with the state to implement and manage the program, has brought sophisticated casefinding and risk-stratification tools to the table, as well as healthcare coaching and other interventions aimed at helping individuals manage their conditions. However, the linchpin of the program is an electronic health record (EHR) that is designed to ensure that all of the providers involved in a patient's care are on the same page.
State takes a long-term perspective
Missouri became convinced that a broader focus on the chronically ill was needed following the implementation of a small DM program that yielded positive results but was too limited in scope. "We were seeing about a 2.5 to one ROI from that effort, but what we learned from that is that people who are chronically ill don't usually have a single disease," says George Oestreich, PharmD, MPA, deputy director of Missouri's Division of Medical Services. "Thus, the DM perspective of [focusing on a single disease] without considering comorbidities would not likely ever realize the results we hoped to attain."
Although Medicaid recipients can be transient, shuttling in and out of the system, Oestreich notes that this is not necessarily the case with the chronically ill. "Many of these recipients fall in our permanently and totally disabled category, so in all likelihood they will remain Medicaid recipients for a very long time," he says, noting that this gives the state the advantage of being able to operate with a long-term perspective in mind.
Under the new CCIP, which began enrolling patients in November 2006, any Medicaid recipient with a diagnosis of diabetes, asthma, gastroesophageal reflux disease, chronic heart failure, or sickle cell anemia is eligible to participate. However, with the assistance of claims analysis and risk-stratification tools, the state is proactively targeting recipients at highest risk for these diseases first. Typically, the first outreach to a recipient is by phone, but once the person agrees to participate in the program- participation is voluntary-the process is handed off to his or her PCP or the physician who has been primarily involved with his or her care. Oestreich explains that the state is able to get physicians on board with the program by paying them an extra fee over and above the traditional office visit fee to carry out a risk assessment of the recipient and make sure the data from that assessment are entered into the program's EHR.
The EHR will then automatically generate a plan of care based on all of the patient information that has been entered, claims, pharmacy data, and rules that have been built into the platform based on evidence-based guidelines. The physician is then free to modify the plan so that it ultimately becomes tailored to the individual patient's needs.
Usability wins over providers
In designing the EHR platform, what APS and the state had in mind was a tool that could perform many functions and serve as a clearinghouse for information, says David Hunsaker, president of APS Public Programs. "What we wanted to do was build a tool that would integrate information across the community and allow all the substantive members of the team . . . involved in a person's care-the consumer, the provider, the care management staff for APS, and others-to be able to interact using a common electronic tool," he says. Consequently, built into the tool is the ability to look at eligibility and demographic data, claims, information about past procedures, and pharmacy data-all of which, Hunsaker notes, is incorporated on a real-time basis. "There is an opportunity for providers to be armed with some really critical quality and historical data that can reduce medical errors, reduce medication errors, and reduce redundancy within the system."
Oestreich acknowledges that there typically is some initial resistance from providers due to the amount of data entry tasks that are necessary in order to populate the EHR, but he maintains that most providers become cooperative once they understand the value that the tool brings to their practice.
"By engaging the call center into the coordinationof- care opportunity, there are fewer missed appointments, and a [greater] opportunity for the patient to respond to the physician's goals and guidelines for treatment," he says.
These patient-support functions are critically important- especially in Medicaid populations, adds Oestreich. "One of the biggest things we find in the physician population . . . is that they are reluctant to engage some of the Medicaid patients because the Medicaid patients [themselves] are not engaged," he says, noting that the reason for this is that patients do not clearly understand what is expected of them. The state is hoping that establishing an electronic communications link between patients and all of their providers will lead to improvements in patient adherence and compliance.
Oestreich adds that the tool also facilitates patient self-reported information, which could give the provider added perspective on the patient's general knowledge of his or her disease as well as information regarding overthe- counter medications or other treatment modalities that the patient may be using.
In addition, the EHR platform includes an e-prescribing function that interfaces with the system's clinical rules engine that monitors and modifies the state's prescription program.
In some instances, getting providers to perform more functions electronically has been a challenge. However, Hunsaker points out that once providers use the EHR system, they tend to like it.
"Our current practice is to try to meet people where they are, so if someone has to deal with us by phone or by fax . . . when we interact with them we try to take them to the Internet so they have the opportunity to see the . . . universe of information that is available to them," he says. "Once they . . . interact with us and the state in a much quicker and efficient way, often they will quit using older technologies."
Provider feedback facilitates QI
One other capability that the EHR system brings to the table is performance monitoring and measurement. The state hopes that if individual providers receive feedback about their own performance on a range of indicators culled from evidence-based guidelines, quality will gradually improve.
Oestreich points out that the state is beginning with quality indicators (QI) that are well accepted, such as HbA1c targets, foot care, and retinal exams for diabetic patients, and peak flow readings and asthma-related ER visits for asthmatic patients.
The approach has been designed with input from practitioners in mind, adds Oestreich. "What we try to do is let our providers know that they will be measured against themselves and their effectiveness with their panel of patients," he says, noting that a frequent complaint of practitioners is that they are at a disadvantage when performance comparisons are made because they have a sicker population of patients than some of their peers. "We are not trying to compare a rural Missouri, high-intensity practice with a metropolitan practice that would be more [involved with providing] basic care without the severity level of illness."
The idea behind this type of feedback is to get providers on board with evidence-based care practices as quickly as possible.
"Most of the studies that I have seen indicate that it is often five to ten years before evidence-based care makes its way down to routine practice in the community," says Hunsaker. "By using systems like this . . . it starts to shorten the cycle time involved with that learning process."
Community focus nurtures acceptance
Another core component of the CCIP is an emphasis on community-based care. Rather than having a centralized call/coaching center that serves all patients, APS is beginning to station health coach and care management personnel directly into large practices, ER facilities, and other high-volume care settings.
The approach facilitates more face-to-face encounters between patients and care coaches, and providers get a firsthand look at some of the interventions that are being employed for their patients.
"By doing that, [the care coaches] become much more a part of that community practice," says Hunsaker.
In some cases, the state has even been able to work out cost-sharing arrangements in which a health coach who is placed in a high-volume practice serves not only Medicaid recipients, but also patients being cared for by that practice.
Such arrangements are prime opportunities for the state, according to Oestreich. "We have found that reaching back to the community to try to find unique ways to integrate our needs into their needs really [nurtures] acceptance of the program," he says.
To achieve greater cost efficiency, APS has tapped into resources available through the government's AmeriCorps program to place lay health educators in community settings.
Traditionally, administrators of AmeriCorps have solicited matching funds from community health centers and then augmented those funds with federal dollars to place a lay health educator in a community setting for two years. "What we have done is provided the local matching funds so that the centers, which are often strapped for funds, are not charged," says Hunsaker. "Their part of the [cost] sharing is granting the physical space, phone, and the various tools the lay health educators need to do their job."
The lay health educators typically perform nonclinical tasks such as resolving transportation difficulties, making sure patients get their prescriptions filled, and making reminder calls when patients are scheduled for appointments. Hunsaker explains that the approach is aimed at providing the kind of "high-touch" outreach that is particularly important to activating patients who are critically ill or morbidly depressed.
Enrollment still underway
The state is still in the early stages of enrolling patients in the CCIP.
At presstime, 90,000 recipients, primarily located in the high-density corridor between St. Louis and Kansas City, MO, were enrolled in the program, but Oestreich points out that there are 130,000 recipients outside of this corridor who have yet to be contacted. He is hoping to have the program fully operational statewide within the next two years.
It is still too early to report clinical or financial results from the effort, but Hunsaker and Oestreich say that early indications are positive, and they are confident that the approach will deliver dividends.
"It's an opportunity to do things that people have talked about quite a bit but have not necessarily acted upon," says Hunsaker. "We think the results are going to be pretty exciting."