Montana Health Improvement Program: New Roles for FQHCs in State Delivery System Reform

Janice Gomersall, MD, FAAFPMedical Advisor, HIP, Montana MedicaidNASHP ConferenceOctober 4-6, 2010

What we will cover

– Care Management vs Disease Management– Previous Program in Montana

– Development of Montana Program– Using FQHCs to deliver the Care Coordination

– Lessons learned– Relevance to health care delivery needs

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Previously….

• Montana Medicaid used a Disease Management Program administered by an out of state vendor

• Concentrated on managing four chronic diseases: Asthma, Diabetes, Heart Failure, and Chronic Pain

• Used both telephonic and community based nurses to assess and manage patients, as well as targeted mailings

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Development of Current HIP

Realization what made patients high riskDevelopment of RFPCMS negotiationsOutreach to CHC and Tribal Health CentersNegotiations for full state coverageIn person meetings with Health CentersEven a stimulus to develop reporting methodology from each site

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Health Improvement Program Introduction

• Predictive Modeling Software identifies high risk patients

• Care managers reach out to those identified patients to find out what is needed to lower their risk

• Care managers, hired by CHC and Tribal Health Centers, work with the primary care providers to develop a care plan

• Care is delivered via in person visits, telephonic, and care plans

• Reporting of data

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Disease Management vs. Care Management

• Disease Management deals with specific diseases, with the idea that if we control the specific disease in a patient we can control costs, complications, and have better outcomes

• Care management deals with the specific patient, with the idea that patients who incur high costs and complications do so because of multiple medical, social, environmental factors which need to be controlled.

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New Health Improvement ProgramAn enhancement to Montana’s current Primary Care Case

Management Program (Passport) that will provide:

Disease Management for high risk / high cost patients (not limited to four disease states)

andPrevention efforts for patients at risk of developing chronic health conditions

Services provided by specially trained nurses, and health coaches, all certified in Chronic Care Professional Program

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Service Providers for the New HIP

Cornerstone : enhancement of community-based comprehensive primary and preventative health care.

Providers are Nurses and Health Coaches employed by Community and Tribal Health Centers who submitted proposals during the State’s procurement process.

All providers are CCP certified within 3 months of hire.

There are 14 centers covering 56 counties

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Northwest CHC Libby

Flathead CHC Kalispell

Partnership CHC Missoula

Cooperative Health Center Helena

Cascade CHC Great Falls

Bullhook CHC Havre

Butte CHC

Community Health Partners – Livingston

Sweet Medical Center Chinook

Central Montana CHC Lewistown

RiverStone CHC Billings

Ashland CHC

Custer Co. CHC Miles City

Fort Peck Tribal Health Center Poplar

Services Provided by Specially Trained Nurses and Health Coaches at FQHCs

• Health Assessment (initial and periodic)• Ongoing clinical assessment (in person and telephonic)• Individualized treatment/action plan• Hospital pre-discharge planning and post-discharge

visits• Self-management education• Group appointments• Tracking and documenting progress• Assistance with and referral to local resources such as

social services, housing, food bank and other life issues

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INTERVENTION for High Risk/ High Cost Patients

• Patients are identified through predictive modeling software.

• Predictive modeling uses claims history and demographic information such as age and sex to calculate a risk score.

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PREVENTION for At risk Patients

• Patients may be identified and referred by primary care providers

• May include patients who have no claims that generate a high risk score or have not yet been diagnosed with an illness

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Reporting of Data

• Patient assessments (SF-12)• Workload management• Time to evaluate, intervene, and follow-up• Patient satisfaction• Provider Satisfaction and knowledge• Main limitation is in resources for data

collection, evaluation in an efficient manner

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COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM

•Montana operates this program as an Enhanced Primary Care Case Management Program under the authority of a 1915(b) Waiver

•Approximately 70% of MT Medicaid members are eligible

•A payment of $3.75 per member per month is made for every eligible member to the Health Center in the region the member resides

•Members in the top 5% of risk scores are provided care management

•Health Centers are paid for all members in their region regardless of who the member’s primary care provider is

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COSTS OF MONTANA MEDICAID HEALTH IMPROVEMENT PROGRAM (cont)

PMPM fee is considered a case management fee and is matched at approximately 70/30 FMAP

•Payment is made through the MMIS directly to each health center

•Total cost of the program is approximately 8% less than the former contract with an out-of-state disease management organization

•Direct Care Management staff went from 4.5 FTE under the old model to 27 FTE (eventually 35)

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Some Reasons Why Health Centers Appreciate the Program

• Recognition (including financially) of what they already do

• Greater capacity to provide services

• Coordination in accessing community services

• Pipeline of MCD clients (including dental)

A stated mission in Montana PCA is to keep patients out of specialty care and hospitals. Care management is in line with this mission.

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Some Reasons Why Providers Appreciate the Program

• Providers can refer into the program

• Provides added service they often do not have staff nor time to perform

• Small practices can take advantage of regionalized care managers

• May add a component of medical home for their practice

• They really don’t have to do anything extra

The delivery of care is from a local source, referring to local resources.

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Lessons learned

• Include everything you need in the PMPM (including database and Medical Advisor)

• Provide general Medicaid training for care managers (eligibility, systems)

• Start working with FQHCs and CMS simultaneously and early

• Develop guidance for program well before launch date

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Summary

Previous ProgramLimited to 4 disease states

Focus on disease management

Out-of state vendor

Four community based RNs

New ProgramInclusive of any combination of

chronic disease statesDisease management and

prevention, care management

Local community-based providers

More than 25 Nurses and Health Coaches based in the communities

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For questions, (or to avoid a really bad time) please contact Wendy Sturn at (406) 444-1292 or wsturn@mt.gov

or Janice Gomersall, MD at jgomers@bresnan.net

Montana Medicaid Health Improvement Program

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