Designing and Implementing Medicaid Disease and Care Management Programs
Section 4: Selecting Care Management Interventions
State Medicaid agencies face unique challenges and must adapt to meet the needs of their population. When designing a care management program, understanding which interventions—the methods used in care management programs to impact member health—are possible, tested, and successful is important. Care management interventions can specifically target members or providers that deliver care. State Medicaid agencies have tried combinations of more than 15 types of interventions to improve member health.
Incorporating information from 13 State Medicaid care management programs in the initial AHRQ Learning Network and supporting literature, this section of the Guide, Selecting Care Management Interventions, provides information to State Medicaid staff about:
- Provider, member, and system interventions.
- Choosing care management interventions.
- Implementing care management interventions.
When choosing interventions, considering their outcomes, timing, and efficacy on selected diseases is important. Many States now are implementing programs that employ a more holistic approach, such as the population-based approach and managing comorbid conditions, as described in other sections, rather than addressing specific diseases. However, this Guide conveys States' experiences as well as the evidence base, which reflect a disease-specific approach. Future editions of the Guide are expected to communicate States' experiences as they implement new program models. For more information on these considerations, please go to Section 7: Measuring Value in a Care Management Program and Section 8: The Care Management Evidence Base.
Provider, Member, and System Interventions
Most often, care management interventions tend to fall into two categories: provider interventions and member interventions. In addition, system interventions, which are designed to promote a culture, an organization, or mechanisms that further program goals, aim to coordinate provider and member interventions. States should choose a mix of provider interventions and member interventions aligned to achieve the same goals. Provider interventions can encourage additional testing and use of evidence-based practices, while member interventions can support self-management behaviors crucial for a member's health (e.g., adherence to diet, exercise, and medication regimens). Together, provider interventions and member interventions can better improve members' health.
States have implemented many interventions through their care management programs. Exhibit 4.1 shows the interventions described in this section and the number of States involved in the AHRQ Medicaid Care Management Learning Network that have implemented the interventions.
Exhibit 4.1. Care management interventions
|Evidence-Based Guidelines and Protocols||10|
|Provider Education and Training||10|
|Provider Profiling and Reports||5|
|Registries and Clinical Information Systems||1|
|Electronic Medical Records, Decision Support, Reminder System, and Other Electronic Communication Systems||1|
|Educational Brochures, Mailings, and Member Letters||13|
|Telephonic Care Management||13|
|In-Person Care Management||11|
Provider interventions attempt to change the way health care providers treat patients. For example, a physician education session on the importance of high-density lipoprotein (HDL) and low-density lipoprotein (LDL) screening is designed to increase physician use of screening for both types of cholesterol. This subsection reviews the types of provider intervention States have used in their care management programs, such as evidence-based guidelines or provider training. Provider interventions also can include practice redesign work that looks at system changes within a practice to support evidence-based best care and practice guidelines.
Evidence-based guidelines and protocols. The most common provider intervention that States use is the distribution of evidence-based guidelines and protocols for care to providers. These guidelines and protocols are designed to standardize and improve patient care across the State. States employ national guidelines for distribution, often adapting them to meet the unique needs of their program. States have faced barriers to provider incorporation of guidelines into practice protocols.
Arkansas has worked with providers to create a set of 80 obstetric and neonatal guidelines for physicians, developed through live videoconferences, Internet comment forms, and formal and informal communication with program staff. The comment period for each of the guidelines is 3½ months, with drafts posted frequently on the program Web site. Arkansas' guidelines are available on its program Web site for all providers; new protocols are distributed quarterly to obstetrical providers.
Indiana, as part of its initial program, the Indiana Chronic Disease Management Program (ICDMP), worked with the Health Department's existing Chronic Disease Advisory Council, which comprised provider groups, private health plans, hospitals, provider associations, and other key stakeholders throughout the State, to adapt national guidelines from guidelines produced by the American Diabetes Association; American Heart Association; National Heart, Lung, and Blood Institute; and American College of Cardiology. To avoid sending conflicting messages to providers, the Health Department and all participating insurance providers distributed the Indiana "consensus guidelines."
State experience with creation and distribution of evidence-based guidelines has produced several lessons:
- Employ cross-payer, statewide guidelines. Provider buy-in is more likely if a provider receives the same guidelines from other payers and Medicaid.
- Involve providers. Giving providers a role in adapting guidelines leads to provider support for them, because providers understand their source and feel they are tailored to the particular needs of their State's population.
- Keep guidelines brief. States have found that providers respond best to one-page documents in an easy-to-read format.
- Identify local physician "champions." These individuals can help convey the importance of implementing the evidence-based guidelines and solicit physician input at the community level.
Provider education and training. Ten of the 13 States involved in the initial AHRQ Medicaid Care Management Learning Network have provided opportunities for physicians to learn more about care management and patient care. In addition, the literature review in Section 8: The Care Management Evidence Base found that provider education and training successfully impacted all of the diseases included in the review. States offer provider education and training to improve patient care and increase provider involvement in a program. The State might send educational materials, for example, hold teleconferences or Web conferences, or conduct in-person sessions. Providers have responded well to opportunities to earn continuing medical education (CME) credit, regarding it as a program benefit.
Arkansas holds several well-attended teleconferences a month, which count for CME credit, to keep physicians up to date on the best current neonatal medical practices.
Indiana's former care management program, ICDMP, held collaborative learning sessions that introduced teams of three (i.e., physician, nurse, and office manager) from physician practices to the program, the chronic care model, practice site improvement techniques, and ways to improve the care of patients with chronic conditions. As part of these sessions, the practices were required to set measurement goals and to report the measures monthly. More than 60 physician practices attended.
Wyoming also provides CME credit for physicians who attend training Web conferences held four to five times a year.
To ensure the success of provider education and training, States should consider:
- Training location. States can ensure greater participation by holding trainings in convenient, central locations or online.
- Evidence base. The literature shows that provider education exerts the greatest impact on measures that target provider processes, such as HbA1c screenings.
- CME credit. States can offer CME credit as an incentive to providers for participating in training sessions.
Practice site improvement. Practice site improvement is a service Medicaid can offer physician practices through care management programs. Care managers can work with physician offices to find ways to improve the care of patients with chronic conditions. Few Medicaid agencies have offered this service because it can prove labor intensive and some physicians might find it invasive. In North Carolina, care managers educate providers when they fail to comply with specific practices (e.g., use of asthma forms). The care managers visit physician offices and map their workflow to identify where the process "broke down." For example, care managers will suggest attaching an asthma form to the chart of every Community Care of North Carolina patient with asthma so the physician can clearly see that it needs to be completed.
Practice profiles and reports. Provider profiles, which can contain any data the State and providers choose, can give providers a more holistic sense of how providers are treating their patient population and how their patients are using health services. Nonetheless, some States have encountered provider resistance to the profiles, because providers often feel concerned that they will be penalized for poor performance. States have learned to "sell" the profiles to physicians as a mechanism for physicians to acquire additional data to which they would not otherwise have access.
States can make the profiles most useful by observing the following guidelines:
- Keep profiles brief. To encourage provider use, profiles should be brief and easy-to-read.
- Involve providers. Because provider involvement is key to the success of profiles, providers should be involved in choosing what data to include in the profiles and adapting the profiles as their needs change.
- Include useful comparisons. Create data comparisons at the level most useful to providers (i.e., county, regional, or State).
North Carolina has worked closely with physicians to create practice profiles. Physicians receive data for their entire Medicaid population that includes:
- Per-member per-month costs.
- Emergency room (ER), hospital, pharmacy, and lab use rates.
- Disease management statistics that change according to provider needs (examples of statistics for diabetics are lipid tests in the last 12 months and eye exams in the last 15 months).
Physicians receive profiles quarterly. North Carolina also shares practice-level data at physician meetings (if physicians are comfortable with the exercise), providing opportunities for practices to benchmark themselves against other practices and creating a competitive environment in a positive sense.
Texas is working with providers to create "client registries," a name Texas chose because it felt "profiles" had negative connotations for providers. The client registries will show providers how their patients compare to patients in other practices. Texas hopes that providers will be able to use the registries to identify gaps in care and to improve their practices.
Provider incentives. Provider incentives and pay-for-performance (P4P) initiatives can help engage providers in care management programs and change provider behavior. Provider incentives do not have to be financial; they can include annual awards banquets to recognize achievements, plaques to hang in offices, and recognition by a high-level official. States can make their P4P initiatives more successful by:
- Engaging providers early. Providers are the key to P4P success and are best able to offer input on what incentives will appeal to them.
- Delivering ongoing provider education. Providers require ongoing education to understand P4P initiatives and how they can take advantage of them.
- Limiting administrative burden. States should design flexible P4P initiatives that limit the administrative burden placed on providers, which might include allowing providers to submit data in different formats (e.g., electronic format versus paper) or accommodating the needs of large health systems that employ providers.
Pennsylvania engages providers with its P4P program, which focuses on three critical areas: assistance with enrollment of eligible patients in the program, collaboration in care management of members, and delivery of key clinical interventions that help improve quality of care and clinical outcomes. To develop the program, Pennsylvania launched a physician workgroup that represented State organizations such as the Medical Society, Academy of Family Practice, Academy of Pediatrics, and Osteopathic Medical Association. The State also involved consumers through the Consumer Advisory Subcommittee, Regional Advisory Committees, and the Pennsylvania Law Project. Provider payments include the following:
- $200 per practitioner for agreeing to partner with the ACCESS Plus program.
- $40 per patient for encouraging newly eligible high-risk patients to participate in the program.
- $30 per patient for furnishing contact information for selected patients.
- $60 per completed Chronic Care Feedback Form every 6 months.
- $17 per patient every 12 months for high-risk patients who are taking their key medications.
The program aims to minimize workflow impact for offices by allowing nurses or office managers to complete the Chronic Care Feedback Form and providing additional assistance to meet requirements. To implement the program, Pennsylvania contacted physicians by mail, hosted an educational Web seminar, and visited high-volume providers.
North Carolina created the Physician Incentive Program (PIP) to reward physicians who excel in meeting care management program objectives and to motivate other physicians to improve. A workgroup of North Carolina physicians met to design PIP structure and to choose measures and reward levels. The workgroup chose measures that would affect cost and could be gathered using existing data sources (i.e., claims data and chart audits):
- Asthma ER rate per 1,000 members.
- HbA1c performed every 6 months.
- Prescribing over-the-counter medication.
The program offers two levels of reward: Excellent Performance and Quality Improvement. To qualify for the Excellent Performance reward, a practice must be the best or be in the top 15th percentile of program baseline. Winning the Quality Improvement reward requires a practice to improve from the baseline by 20 percent and to exceed the 50th percentile of program baseline. The incentive awards will be based on network performance; networks can develop their own methods of internal reward distribution.
Lessons Learned: Provider Interventions
Patient registries and clinical information systems. Patient registries can help providers track patient care to reduce duplication of services, address patient issues, and coordinate care with care managers. Physicians often are unaware of a patient's multiple ER visits or entire prescription drug regimen, so a patient registry gives providers data they cannot access otherwise. However, challenges to creating patient registries sometimes occur. Some States, for example, might have insufficient resources to create a registry or to buy one. States also have found that physicians might be reluctant to use registries for several reasons (e.g., the system cannot be used for billing). States can try a number of methods to encourage providers to use their system:
- Involve providers in creating the system. Ask them what information would induce them to use the system (e.g., pharmacy data, ER visits).
- Pilot the system. Test it at a few provider sites and incorporate provider feedback into the program.
- Tie the system to claims data. If possible, create a system that allows providers to enter data for claims purposes.
- Give providers data they would not have otherwise. Such data might include pharmacy data or information on ER visits.
- Offer provider incentives. Providers might be more likely to enter data (e.g., lab values) into the system if given an incentive.
Iowa has developed an online health information tool, the Iowa Electronic Medical Records System, which it is testing currently at five sites, including three federally qualified health centers (FQHC) and the county hospital system. These sites are using the system daily and providing feedback to the State. As Iowa has received feedback, it has modified the information in the system (e.g., the State added ER and urgent care use data). The State adds claims and prescription data to the system weekly.
Wyoming has developed the Web-based Total Health Record (THR), an electronic health record, for all Medicaid providers. All care team members, including the patient, physician, payer, care manager, and pharmacist have access to THR. To build support and obtain input on the Total Health Record, the State:
- Convened an advisory board of providers, consumers, and legislators.
- Established a provider collaborative that helped select measures to evaluate the initiative.
- Offers financial incentives to encourage provider participation.
Healthy People 2010 defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." In creating outreach and enrollment materials, program staff must understand that the average Medicaid beneficiary possesses a Grade 4 reading competency. Therefore, materials must be written in an easily understandable way. Techniques to make written materials more comprehensible to people with low health literacy include:
Experts suggest that testing materials with the target audience will ensure appropriate presentation and content.
Member interventions attempt to change member behavior. For example, self-management education can teach and empower members with heart failure to weigh themselves daily and to adhere to their medications. Member interventions might include the use of resources such as educational materials or workshops, telephonic and in-person care management, or home monitoring devices.
Educational materials. All of the initial 13 States involved in the AHRQ Medicaid Care Management Learning Network include educational materials as an intervention in their care management programs. For this intervention, States typically target low-risk, low-cost members who might have their disease under control. States might, for example, mail members disease-specific information, as well as information on when to use the ER versus their primary care provider. Although this intervention is relatively inexpensive, questions of its efficacy arise. Member addresses often are incorrect and program staff have no way to ensure that members are reading the materials. States might also question the cost effectiveness of sending information to all eligible members and instead choose to send materials to certain members using selection criteria. The evidence base for educational materials shows that their efficacy varies by disease and is most effective for asthma.
After deciding to use educational materials, States can strive to create the most effective materials by considering:
- Non-English-speaking populations.
- Literacy levels.
- Material length.
- Relevant audience.
- Available materials.
The Medicaid population includes non-English speakers and low-level readers, so educational materials ideally should be printed in the common languages of the Medicaid population and should be developed for a Grade 4 reading level.
States must consider which members will receive the educational materials. To send appropriate materials, program staff can identify members through claims. For example, if a member visits the ER twice in a month, staff could automatically send him or her a brochure on appropriate ER utilization. States could choose to send materials on diabetes to all diabetics or to send materials only after a diabetes-related visit to the ER. In addition, States can send educational materials to members identified by care managers. If a member identifies that he or she wants to adopt a healthier diet, care managers can offer to share materials on health diets as followup.
In many cases, creating these educational brochures from the beginning (or without help) is unnecessary. Other State Medicaid agencies often are willing to share materials they have already developed. Partnering with local disease-specific organizations (e.g., local chapter of the American Heart Association, State diabetes prevention and control programs) to produce materials also is possible.
Oklahoma and North Carolina send postcards to care management program members with information on appropriate ER utilization.
Indiana's former program, ICDMP, developed disease-specific materials that included information on diet (e.g., eating in restaurants, foods high in sodium), medication adherence, blood pressure, and physical activity.
Care management. Care managers can serve many functions, depending on the design of the care management program. They might assess a patient's health status, for example, or coordinate a patient's care team, develop a care plan with the patient, teach self-management, remind the patient of physician appointments, visit a physician with a patient, grocery shop with a patient, and more.
Telephonic care management. Care managers can use the telephone to contact patients regularly, monitor patient status, deliver patient education and counseling, give appointment reminders, and facilitate peer support and referrals for coping with illness.u Evidence suggests that telephonic care management can improve outcomes for patients with asthma, diabetes, congestive heart failure (CHF), and chronic pain. In addition, telephonic care management can improve self-management behaviors, like proper use of medication. Scripts and guidelines to standardize telephonic care management and outreach might prove beneficial.
In-person care management. Care managers can include in-person visits in their care management intervention. The literature review in Section 8: The Care Management Evidence Base found that in-person care management was the most effective intervention across all diseases. In-person care management is the intervention most likely to impact clinical outcomes, utilization, and cost. Although in-person care management offers advantages (e.g., environmental factor identification, trust-building, patient values) and has a stronger evidence base, it also is more costly than telephonic care. In-person visits might occur for an initial visit, regularly, or as needed.
- Initial visit. States might have care managers meet members in person for the first time to conduct a thorough assessment of the individual and potentially the home environment. Home visits allow care managers to acquire a sense of the environmental factors affecting the member's health (e.g., dust or mold in an asthmatic's home). An in-person visit also can help build trust between the member and the care manager.
- Regular visit. Regular visits are most feasible if the care manager works in a physician practice or community health center. This situation allows the care manager to sit in on patient visits and work more closely with the patient's care team.
- As-needed visits. In this situation, care managers see patients in person when necessary but not on a regular schedule. If a patient is having difficulty using a glucometer, for example, the care manager can visit the patient and teach him or her how to use the device correctly. Care managers also might schedule office visits with the patient and his or her provider. During the visit, the care manager facilitates communication between patient and provider to help the patient learn communication techniques.
Checklist: Care Management
A combination of in-person and telephonic care management has proven an effective intervention.v
Indiana's initial program, ICDMP, offered care management on two levels: a call center and nurse care managers. All eligible members first were stratified as either low risk or high risk. The call center assumed responsibility for making the first call to members of both strata to introduce them to the program and assess their general health status. Care coordinators with a customer service background (not clinical), supervised by nurses, staffed the call center. After the first call, high-risk and low-risk members took two different tracks. High-risk members were assigned to nurse care managers who worked with them for 4-6 months. Low-risk members received calls and educational materials quarterly. After a high-risk member was in care management for 4-6 months and was ready to self-manage, the nurse care manager transitioned him or her to the call center for quarterly contact.
Pennsylvania works with its vendor, McKesson, to provide both in-person and telephonic care management to members. First, community-based health workers locate the member, explain services and benefits, help locate basic community resources (e.g., dentists), and help the member call the nurses. Then, community-based registered nurses deliver care management services to members. Interventions can be telephonic or they can be in-person if the member cannot be reached by telephone. The registered nurses work with the member's physician to coordinate care. Nurses:
- Encourage members to visit their primary care provider.
- Teach members to recognize signs or symptoms of disease process.
- Increase members' self-management skills to take better care of themselves.
- Coordinate with the provider's plan of care through ongoing education.
- Promote a healthy lifestyle.
Consumer incentives can be used for various reasons, including encouraging members to engage in healthy behaviors, self-manage their disease, or participate in a wellness program. By incentivizing members to adopt healthy behaviors, many States are attempting to give members a greater stake in improving their health care.
States can offer a variety of incentives to encourage members to engage in healthy behaviors, including financial incentives, such as cash, gift cards, small gifts, lotteries, and redeemable credit. Some States might even choose to waive registration fees as an incentive for signing up for a tobacco cessation or weight management class.
Many programs choose to collaborate with community organizations or State departments, such as the YMCA or the Department of Public Health, to provide services to members. Through these collaborations, programs can offer reduced or free enrollment programs that promote healthy behavior. Kansas, for example, has an agreement with a local YMCA to provide scholarships to care management members to use its gym.
When deciding where and what incentives to apply, programs should consider members' preferences and needs. States might convene focus groups or use surveys to collect information from members on behaviors they wish to change, incentive preferences, and barriers to engaging in healthy behaviors.
Self-management education and training. Self-management is what people do every day: make decisions about diet and exercise, monitor their health, and adhere to their medication regimen. Everyone self-manages, but many people do not make decisions that improve their health-related behaviors and clinical outcomes. To make good health decisions, patients must be informed and activated.
- Informed patients possess the knowledge they need to make correct decisions. For example, an informed diabetic understands the importance of regular blood sugar testing.
- Activated patients are involved in their own care, set goals, and develop problem-solving skills.
Care management programs have several options to empower and prepare patients to manage their health and health care. One option is to incorporate self-management messages and education into telephonic and in-person appointments. This option requires training care managers in self-management support. Care managers learn about collaborative goal-setting and shared decisionmaking. In this management style, the patient sets the agenda for what he or she wants to work on. For example, when a patient wishes to focus on smoking cessation, the care manager works with him or her on a plan to quit smoking, even if the care manager feels that working on the patient's diet is more important. During this process, States also can provide the tools necessary to self-manage (e.g., weight scale, glucometer).
Indiana's initial program, ICDMP, infused the general principles of self-management into its nurse care management protocols as well as into telephone call scripts and written materials. The State's nurse care manager vendor recruited nurse care managers who are comfortable and successful with teaching patients self-management techniques. Nurse care managers worked closely with patients to set self-management goals, allowing them to choose their goal and working with them to achieve it. Indiana also encouraged self-management by setting a date for program graduation. Nurses worked with patients to create self-management plans and to become independent.
Another option for bringing self-management into a Medicaid care management program is to adopt an approach like the Stanford Chronic Disease Self-Management Program (CDSMP), which is based on small-group workshops. Held 2 hours a week for 6 weeks, the workshops are designed to help patients gain confidence in their ability to control their symptoms and understand how their health problems affect their lives. They provide skills to coordinate all things the patient needs to manage his or her health and remain active. Moreover, they cover techniques to deal with problems such as frustration, fatigue, pain, isolation, appropriate use of medication, exercise, communication, nutrition, and making informed treatment decisions. Two trained leaders—one of whom, preferably, is a peer with a chronic condition—facilitate the workshops.
Rhode Island Medicaid is in the process of bringing CDSMP to the State in conjunction with the Department of Health and the Department of Elderly Affairs. In October 2006, 17 people throughout the State were trained to be "master trainers," at a cost to Rhode Island of approximately $23,000, including the session, trainers, and materials. These master trainers can conduct workshops and train other workshop leaders. As of April 2007, six workshops had been conducted, from which the State will begin identifying potential peer leaders for leadership training in Fall 2007.
Home monitoring devices. As new technology becomes available, tools to help patients and care managers monitor patient health are becoming more common in State Medicaid care management programs. Home monitoring devices might require patients to:
- Answer a series of questions about their health (e.g., weight gain in the past 24 hours).
- Monitor their health (e.g., reminders to take medication, measure blood pressure).
- Answer health education questions (e.g., "Do you understand what to do if you feel short of breath?").
Medicaid agencies are still piloting many of these home monitoring devices, so their efficacy for the Medicaid population has yet to be determined. The devices also can prove expensive.
Wyoming's care management program provides high-risk members a home monitoring device, Health Buddy, which questions them about their health and quizzes them on health education. Members enter information daily in response to five to eight questions based on their chronic condition. They might be asked about their blood sugar level, for example, weight gain, or shortness of breath. Nurse care managers call all Health Buddy users at least once a month, and they call immediately if answers to the questions indicate the member's health might be in danger. To receive a Health Buddy, members must have at least three conversations with a care manager, be high risk, and be interested in using the device. Health Buddy costs approximately $40 per member per month (PMPM) and $300 if the unit is not returned. Wyoming has found that about 50 percent of members who have a Health Buddy use the device consistently.
Iowa is piloting a telemedicine device, Pharos, for 250 members of its CHF population. Members in the Pharos pilot are required to call a toll-free number once a day and answer five machine-prompted questions. A nurse care manager calls the member if he or she answers two or more questions positively, indicating the member might need additional care management or medical attention.
u. Available at:: Piette JD California Health Care Foundation. Using telephone support to manage chronic disease. http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=111784. Accessed April 2, 2008.
v. Bella M, Cobb E, Rothstein, J. (Center for Health Care Strategies. Health supports for consumers with chronic conditions. http://www.chcs.org/usr_doc/ESMVPFINAL.pdf. Accessed October 25, 2007.