Pennsylvania Designs New Medicaid Program With AHRQ Tools

Prevention and Care Management
December 2009

The Commonwealth of Pennsylvania's Office of Medical Assistance Programs changed its Medicaid care management program as a result of participating in the Medicaid Care Management Learning Network, an AHRQ Knowledge Transfer project. The Learning Network has had significant impact on the Pennsylvania program in two areas:

  1. The increased provision of in-person care management services.
  2. Program design and planning.

The Learning Network serves State Medicaid agencies that operate care management programs for chronically ill beneficiaries in fee-for-service plans or primary care case management programs. Pennsylvania is one of 17 States participating in the Learning Network.

The Learning Network provides expertise to participating States in four key areas critical to ensuring a quality-driven care management program:

  • Helping patients become active in their care.
  • Encouraging provider participation in care management programs.
  • Creating program interventions aligned with the State's measurement strategy that will impact patient care.
  • Designing valid and reliable evaluations to determine program success.

During its three-year participation in the Learning Network, Pennsylvania staff planned a new care management program. It also improved its current care management program as a result of participating in peer-to-peer learning between States to share lessons learned and program successes.

The experience of Illinois particularly had an impact on Pennsylvania's approach for providing in-person care management services. Pennsylvania learned about Illinois's approach to place nurses in high-volume hospitals and community health centers. Nurses hired by the State's vendor assist members with discharge planning, filling prescriptions prior to discharge, and following up to ensure that patients complete an office visit with their primary care physicians. Illinois also divided its State into zones and deployed vendor staff to each of these areas to provide in-person care management.

Based on discussions with AHRQ staff and Mary Miller, a Program Manager at Illinois Healthcare and Family Services, Pennsylvania officials improved their approach to providing in-person care management services for their current program by increasing the number of community-based clinical staff members in 2007. Pennsylvania's vendor hired additional nurses to provide in-person care management services to high-risk, high-cost Medicaid patients.

AHRQ staff also provided recommendations to Pennsylvania officials for its new care management program based on AHRQ's publication, Designing and Implementing Medicaid Disease and Care Management Programs: A User's Guide.

Pennsylvania staff used AHRQ's recommendations to achieve the following:

  • Define the terms "disease" and "case management" in its request for proposals.
  • Select conditions for the new program to target and require vendors to target co-morbid conditions in the request for proposals.
  • Specify vendor requirements for engaging primary care physicians using the medical home approach.
  • Require vendors to use consumer incentives to encourage appropriate service usage.
  • Design requirements for coordination between physical and behavioral health providers.
  • Revise reporting and monitoring sections of the request for proposals.

As a result of AHRQ's recommendations, Pennsylvania officials designed a new program focusing on patients with multiple chronic conditions. Similar to its current program, the new program will serve members in its primary care case management program. State staff will work with a vendor to provide care management to these selected clients through in-person care management, telephone care management, educational materials, and the medical home.

All patients will be required to have a medical home—a primary care physician or practice that provides patient-centered, coordinated care. Providers will receive enhanced compensation for offering expanded office hours, maintaining open access to new patients, and providing care aligned with evidence-based guidelines.

In reference to AHRQ's recommendations for the new program and its facilitation of peer-to-peer learning with other States, David Kelley, MD, Chief Medical Officer, Department of Public Welfare, says, "Gaining insight from AHRQ and other States about improvements in program design was extremely valuable. Lessons learned from this experience were essential in redesigning an innovative RFP for our new program."

For more information on the Learning Network, go to:

Impact Case Study Identifier: 
AHRQ Product(s): Medicaid Medical Directors Learning Network
Topics(s): Chronic Care: Self-Management, Policy
Geographic Location: Pennsylvania
Implementer: Commonwealth of Pennsylvania
Date: 12/01/2009
Page last reviewed October 2014