Texas Health and Human Services Commission

1
Texas Health and Human Services Commission

• Medicaid Disease Management Program Overview
• Texas Association of Community Health Centers
  Annual Meeting
• October 26, 2004
• Maureen Mangotich MD, MPH
• Medical Director, Provider and Community Outreach
• McKesson Health Solutions

2
Agenda

• Medicaid DM Program History
• DM Program Overview
• Opportunities for Collaboration with Community
  Health Centers

3
Legislative Mandate

• The Texas 78th Legislative Session (2003)
  mandated State agencies to focus on the
  healthcare needs of the underserved and needy
• The legislation mandates measurable financial and
  clinical results, and proactively reduced budgets

4
State RFP for Medicaid FFS DM Program

• Program Goals
• Improve health status
• Increase adherence to national evidence based
  guidelines
• Reduce overall medical costs
• Savings expectations a minimum of 5 of total
  expenditures for the eligible population served

5
Why Disease Management?
Next Clinic visit
Clinic visit
1-12 months
Treatment Plan
Late Rx Refill
Avoidable IP admit
Acute Sx ER visit
6
State RFP for Medicaid FFS DM Program

• Program Objectives
• Improve continuity of care
• Increase access to preventive care
• Enhance clients relationship with their primary
  caregiver and other providers
• Improve coordination and collaboration among
  healthcare providers and other community
  resources
• Reduce unnecessary hospital admits, total
  hospital days, ER visits

7
DM Vendor Selection

• Multiple bidders summer 03 for 1/04 award
• Initial plan to award South and North separately
• 2 Finalists
• 7/1/04 McKesson chosen for entire state
• Major reasons
• Guaranteed savings
• Risk contract 100 of fees
• 60 day implementation

8
McKesson Health Solutions Profile

• Six care centers
• 4 in Mainland USA, 1 in Puerto Rico, 1 in
  Westlake TX
• Employ 400 nurses in N. America
• Nurse Advice Line (Triage Services)
• 25MM covered lives in Triage
• Disease Management Programs
• Asthma, COPD, Diabetes, CAD, Heart Failure
• 80 DM clients (MCO, Medicaid, Employers, Pharma
• 8 Medicaid Contracts Colorado, Florida,
  Mississippi, Montana, New Hampshire New Jersey,
  Oregon, Puerto Rico, Washington
• Accredited by JCAHO, NCQA, URAC

9
McKesson DM Program Results

• 89 increase in ACE-inhibitor prescriptions
• 24 increase in annual flu vaccinations
• 114 increase in pts weighing themselves daily
• 155 increase in pts keeping a weight record
• 44 increase in pts following a low-salt diet

• 33 increase in pts who do SMBG monitoring
• 70 increase in aspirin use
• 22 reporting lower blood glucose levels
• 20 show improved functional status

• 91 increase in patients with action plans
• 85 in asthmatics who own peak flow meters
• 34 increase in asthmatics using spacers

10
Economic Impact

• Behavior changes lead to improvements in
  compliance, functional status, symptom control,
  and reduced service utilization

11
The Texas Medicaid Enhanced Care Program

• Disease Management
• Care Coordination
• 24/7 Triage Services

12
Who is eligible to participate?

• Eligible Fee-For-Service Medicaid clients with
  asthma, diabetes, heart failure, CAD and COPD
• Opt Out Program
• Clients are automatically enrolled unless they
  choose not to participate

13
Identification of Program Enrollees
State Data
Providers
Claims
Eligibility
Target Clients
Client- Provider Links
Medical Home
14
DM Services Support Pts Between Office Visits

Community Support Services
MD Reports Clinical alerts, pt updates
24 x 7 nurse triage service
Provider mailing with patient list
Pt mailings educational materials, reports,
reminders
Triage Navigate

Audiohealth Library (English and Spanish)
Face to face nurse contacts
Patient
M.D.
R.N.
Coordinate

Promotora outreach/ enrollment contacts
Proactive Outbound Nurse Calls
Care coordination services
15
Evidence supporting nurse triage
Sources (1) The Robert Wood Johnson Foundation,
Annual Report, 2000 (2) Internal
McK Research, 2001 and 360 pilot results, March,
2002 (3) National emergency care utilization
report -NCHS, 2001 (4) Harris Interactive and
Harvard School of Public Health Research Study,
2000 (5) Cyber Dialogue and Deloitte Touche,
Strategy and E-Health, 2001 (6) Health Affairs
Article, 2001 and Agency for Healthcare Research
and Quality (7) Modern HealthCare, June, 2000
source Agency for Healthcare Research and
Quality (8) The Dartmouth Atlas, 2000

16
A recent ground breaking RCT just competed by the
Geffen School of Medicine at UCLA compared
McKesson nurse triage of symptoms to a panel of
Board Certified Pediatric Emergency Medicine
Specialists from a major Academic Institution
the result no significant differences in care
recommendations
Proof that our triage clinical content and nurse
quality management processes are working.
80
70
60
50
69.6
70.6
40
Physician
Nurse
30
20
19.0
18.7
10
11.4
10.7
0
ED/Urgent Care
Office Care
Self Care
Randomized control study N 3,193 medical advice
pediatric calls Study period was 11
months Referred to 3 categories ED/Urgent Care,
Office Care, Self Care
Callers were randomly routed to either a
physician or nurse. The caller was then triaged
and the result were recorded. There was no
significant difference in where the physician
recommended the caller seek care vs where the
nurse recommended the caller seek care
17
Tiered Interventions based on risk
Proprietary Risk Stratification
AT RISK (Level 2)
HIGH RISK (Level 3)
STABLE (Level 1)
Level 1 services
Level 1 services
Educational Mailings
Audio health Library
Level 2 services
Proactive calls
24x7 nurse line
Case mgmt referrals
In-person visits
Provider Alerts
Home Monitoring Devices
18
DM Program Launch November 2004

• DM Welcome letter
• Toll free number
• Business reply card
• Calling card incentive
• Enrollment Contacts

Patient Communications
19
Physician CommunicationsIntroductory Mailing

• Cover letter with list of physicians patients
  eligible for enrollment
• Program Information
• Clinical guidelines
• Stepped Inserts
• Program benefits to pts, provider
• FAQs

20
Introductory Materials Provided to All clients
Eligible to Participate

• Personalized letter
• 4th grade reading level
• Magnet with Toll Free number
• Easy to read educational pamphlet
• Mail or hand delivered

21
Personalized Patient Education

• Assess Maslow's hierarchy of needs, Prochaska/
  readiness to change, clinical, functional,
  utilization, knowledge level, risk metrics and
  QOL
• Teach Condition knowledge, self-management
  skills, medication compliance,
  prevention, proactive management
• Reinforce improvement Action plans, monitoring,
  24/7 nurse advice line, health counseling and
  fulfillment
• Modify Goals Re-assessment 6 and 12 months,
  re-education, monitoring, etc.

22
Personalized Support Action Plans Developed for
All Program Enrollees

• Prevention
• Education
• Screening and testing
• Medication reminders
• Warning signs and symptoms
• Provider partnering

23
Personalized Support Special Needs Coordination
and Physician Alerts

• Compliance and adherence
• Three Severity Levels
• Level 3 alerts faxed to office/clinic after nurse
  call
• Access concerns
• Utilization issues
• Financial issues

24
How do Providers Benefit?

• Improvement in patient self-mgmt skills
• Better adherence to medical regimen
• Earlier recognition of decompensation and PCP
  contact for urgent evaluation
• Improved continuity of care
• Reduced no-shows for office appts
• Fewer after-hours calls
• Fewer calls to nurse staff during office hours

25
Opportunities for Collaboration
with Texas Community Health Centers

• Program Launch (first 90 days)
• Orient CHC staff to new program
• Review lists of identified DM enrollees
• Validate identified cases and provider linkages
• Recommend appropriate level of DM
  services/support
• Identify CHC clients not currently on DM program
  rolls who might be eligible
• Recommend CHC Representative to serve on
  Statewide Provider Advisory Board

26
Opportunities for Collaboration
with Texas Community Health Centers

• Post Launch Period
• Coordinate resources to optimize appropriate
  access to primary care services
• Promote 24x7 telephone triage service to reduce
  office/ER visits for c/o appropriate for
  self-care
• Expedited appt access for DM managed clients with
  urgent clinical issues

27
Opportunities for Collaboration
with Texas Community Health Centers

• Longer Term Goals
• Demonstrate value of collaborative care
• Number of similarities between DM program and
  CHCs in mission, approach, services offered
• Share tool kits
• Educate clinicians in population management
  tools, techniques

28
Program Contact Information

• In-State Program Manager
• Barbara Ramsey [phone]
• HHSC Senior Policy Analyst
• Geri Willems [phone]