AS OUR NATION looks for ways to achieve what Dr Berwick, administrator for the Centers for Medicare & Medicaid Services, called Centers for Medicare & Medicaid Services's Triple Aim, that is, improving the health of the population, enhancing the patient experience of care (including quality, access, and reliability), and reducing the per capita cost of care, case management and care coordination are considered contributors to the accomplishment of these ends (Berwick et al., 2008). When the National Quality Forum convened the National Priorities Partnership, Janet Corrigan, National Quality Forum president and chief executive officer, said, "We have an urgent need to fix healthcare and must have a common vision to succeed. The National Priorities Partnership is aligning resources and actions to focus on reform in the areas where change can make the biggest impact." She went on to name the top-6 priorities for the nation, of which care coordination was one. The others were population health, patient and family engagement, safety, palliative/end-of-life care, and overuse (http://www.nationalprioritiespartnership.org/Priorities.aspx).
The new Patient Protection and Affordable Care Act, 2010, also addresses the need for care coordination. Provision 2703 provides states with the option of enrolling Medicaid beneficiaries with chronic conditions into a health home. Health homes would be composed of a team of health professionals that provide a comprehensive set of medical services, including care coordination. Section III, Improving the Quality and Efficiency of Health Care, provides incentives for doctors and hospitals to improve quality by fostering care coordination to help reduce harmful medical errors and health care-acquired infections (Patient Protection and Affordable Care Act, 2010).
The confluence of these health care reform events creates a "perfect storm" for case managers/care coordinators. Integrated care coordination can help Centers for Medicare & Medicaid Services reach its Triple Aim and National Quality Forum achieve its "care coordination" priority in a funded health environment through Patient Protection and Affordable Care Act reimbursement incentives. Case managers should take their rightful place at the table as improved care at lower cost is sought.
BACKGROUND
Historical perspective
The field of case management began in the 1800s with the establishment of social casework. By the mid-20th century, case management had developed as an independent discipline that coordinated care for individuals who needed extensive health care services (Schilling et al., 1988). The term case management first appeared in social welfare literature during the 1970s but the concept evolved from community service coordination, which began at the turn of the century. The case management approach, which provided clients/patients (hereafter patients) with assistance as they followed treatment recommendations and initiated healthy behaviors, produced the desired results of patient satisfaction, provider satisfaction, and payor satisfaction because the patient received quality, cost-effective care (Klainberg et al., 1998). Distinct approaches to case management emerged in nursing with a focus on illness management and in social work with a focus on advocacy (Huber, 2002).
Care and case complexity
The Institute of Medicine identified complexity in the health care system and the challenge of uncoordinated care as a major contributor to the quality gap in US health care (Committee on Quality of Health Care in America & Institute of Medicine, 2001). Integrated models of care have been introduced as a solution to address system-based complexity and care fragmentation, also known as "care complexity" (de Jonge, Huyse, & Stiefek, 2006). The Case Management Society of America's (CMSA's) 2010 Standards of Practice recognize that system complexity is a primary reason for poor health outcomes and promote a holistic approach to case management that fosters coordination of medical, behavioral, psychosocial, and health system concerns, that is, integrated case management (Case Management Society of America, 2010).
Integrated models of care management are also important for patients who have multiple diagnoses; physical and mental health comorbidities; impairment and disability; treatment resistance; and personal, social, and financial issues. These patients illustrate a second type of complexity, that is, case complexity (de Jonge et al., 2006). These are the top-5% of patients who use 50% of health care resources (Zuvekas & Cohen, 2007). The potential for integrated care facilitation to improve patients with case complexity and to reduce health services utilization has been demonstrated in Australia and North America where integrated teams and care coordinators assisting with health care needs of older patients reduced hospitalizations and institutionalizations (Bird et al., 2007; Kodner, 2006.)
Medicaid policy makers are focusing attention on these high-cost, high-utilizing patients with case and care complexity (Billings & Mijanovich, 2007). Nationwide, 4% of Medicaid enrollees account for nearly half of all Medicaid spending (Sommers & Cohen, 2006). Many states have engaged in efforts to provide disease management or case management for such high-utilizing Medicaid fee-for-service (FFS) patients. Disease management can be effective in reducing costs of high utilizers if properly configured but typically, it targets single diseases (Goetzel et al., 2005). Traditional case management also shows promise as a means of improving outcomes and reducing total cost of care but, typically, does not integrate medical and behavioral support or address health system issues that create barriers to improvement. Integrated case management, which will be discussed in this article, is designed to assist complex patients with multiple and diffuse comorbidities (case complexity), the overlap of medical illness and behavioral conditions (case complexity), psychosocial issues (case and care complexity), and health system impediments to improvement (care complexity) in complex Medicaid patients (Kathol et al., 2010).
METHODS
New York State's chronic illness demonstration project
In New York State (NYS), 20% of the 4 million Medicaid beneficiaries account for 75% of the program's 47 billion dollars in annual expenditures (NYS Department of Health [DOH]). To address this problem, the NYS-DOH invited organizations to submit proposals to provide integrated care coordination for high-cost, high-utilizing Medicaid FFS beneficiaries to improve their health outcomes and reduce costs. The goal of the project was to establish innovative interdisciplinary models of care, to advance quality and affordability, and to improve outcomes in complex Medicaid FFS beneficiaries who are exempt or excluded from mandatory managed care. The demonstration projects were to be distributed across NYS. Qualifying organizations were required to have an integrated system of care, a community provider network that ensured coordinated care and service delivery across the continuum of medical, mental health, rehabilitative care, and social services.
The target population for chronic illness demonstration projects (CIDPs) included individuals with chronic medical conditions, mental illness, chemical dependency, developmental disabilities, and mental retardation and some requiring long-term care. It was anticipated that this group would also have a high level of homelessness and housing instability. Such individuals did not receive coordinated care in the NYS health system. Most lacked medical homes in which they can receive preventive screening and early intervention. As a result, emergency departments and inpatient hospital admissions became their primary source of health care, a costly and inappropriate use of health resources that was associated with poor health outcomes.
A case-finding algorithm, that is, a logistic regression technique to produce a risk score that predicted individuals at high risk for rehospitalization (Billings & Mijanovich, 2007), identified patients for inclusion in the CIDPs. Variables in the algorithm included prior hospital admissions, emergency department visits, outpatient utilization claims, pharmacy and durable medical equipment use, diagnostic information from inpatient and outpatient claims, and patient demographics. Qualifying patients were all high-cost, high-risk Medicaid FFS recipients aged 18 years and older.
The duration of CIDP contracts was 3 years during which contractors were to provide integrated services to qualifying patients. To monitor the program, the NYS-DOH required contractors to provide reporting on preenrollment and postenrollment events and on program activities, including the number and type of interventions, initial and ongoing health assessments, initial and ongoing patient perception surveys, indicators of an established medical home, and indicators of care plans and actions. Contractors were to submit quarterly and annual reports. Evaluation of each program's effectiveness was to be conducted by an independent organization that compared demonstration project outcomes versus a risk- and cost-adjusted comparator group. Contract grants of up to $5.2 million for the 3-year period were awarded to 7 geographically diverse contractors.
Westchester cares action program
The Westchester Cares Action Program (WCAP), a partnership of Hudson Health Plan (Hudson) and Beacon Health Strategies (BHS), was one of 7 CIDP contractors chosen in early 2009. Target enrollment for the plan was 250 eligible patients identified in Westchester County by the DOH as candidates for this project.
Hudson and BHS had been early adopters of a collaborative care coordination initiative and pioneers in the development of an integrated comanagement model. Hudson Health Plan, a not-for-profit NYS Medicaid managed care organization ranked number 1 in member satisfaction for the previous 8 years by the NYS-DOH Consumer Assessment of Healthcare Providers and Systems and number 1 for the last 2 years in Quality Assurance Reporting, was founded in Westchester County in 1985 by a group of community-based health centers. It now serves more than 100 000 members in 6 counties in the Hudson Valley Region. Beacon Health Strategies, a stand-alone managed behavioral health organization, provides services to approximately 5 million members, of which 80% are publicly funded. Hudson and BHS had had a long-running successful partnership, comanaging medical and mental health services for common members since 1998. Their combined community provider networks, that is, the 4 largest outpatient provider groups, 3 of 4 hospitals in the area, and 20 community-based organizations (CBOs) in Westchester County, made them well suited to deliver coordinated access to medical care, mental health and substance abuse treatment, and related support services as a part of the CIDPs. Furthermore, Hudson and BHS were located in the same office building. Leadership and staff of both organizations shared a philosophical approach and deep commitment to care coordination.
The WCAP designed a comprehensive care coordination program for high-risk, high-need, high-utilizing, and high-cost individuals currently enrolled in the Medicaid FFS program in Westchester County, New York. Its goals were to
1. Provide patient/caregiver-centered integrated care;
2. Facilitate care in appropriate settings, such as health homes;
3. Lessen emergency department visits, hospitalizations, and readmissions;
4. Increase medication adherence;
5. Expand cost-effective treatment choices;
6. Lower medical and behavioral health complications from chronic disease; and
7. Reduce inappropriate procedures and laboratory tests.
To achieve these goals, the WCAP used an integrated case management approach, which required no interdisciplinary "handoffs." Another hallmark of the WCAP was the "feet on the street" approach, that is, enrollment and assessments are conducted where patients lived, preferably face to face. With its feet to the street approach, the WCAP used its knowledge of community services and resources to serve its patients.
Beacon Health Strategies' Behavioral Health Management Software was adapted to serve as the enrollee documentation system. It was enhanced to include medical assessment information, integrated case management tools, and multidomain care plans. The software design facilitated comprehensive interdisciplinary assessments and care coordination and allowed outcome documentation.
The WCAP team
Westchester Cares Action Program team leadership consisted of a senior project executive and program codirectors, one from Hudson and one from BHS. The senior project executive and the Hudson codirector were both nurses certified in case management (Llewellyn & Leonard, 2009). Under them was the feet on the street integrated care coordination team, comprising registered nurses, a social worker, and support personnel. Physician consultants, who assisted care coordinators in care plan decision making, included a family physician medical director from Hudson and an experienced addictions psychiatrist from BHS.
The senior project executive was responsible for performing high-level administrative support and technical program assistance. She planned and helped to implement the program's daily operations. She also ensured that NYS CIDP operational requirements and deadlines were met.
A seasoned registered nurse supervisor managed the integrated care coordination team. It consisted of 2 registered nurses and 1 social worker care coordinators; 2 integrated care coordinator support personnel, who were responsible for outreach to members; and 1 certified peer support specialist. The care coordinators managed the caseload and participated in all quality assurance/quality improvement and management activities. They identified medically and/or psychosocially complex issues that required care management interventions. The care coordinator support personnel located patients and met with them to explain the program and enroll them. The peer support specialist, a mental health consumer trained to help those diagnosed with psychiatric conditions and/or chemical dependency, promoted self-advocacy, accompanied managed patients to clinical appointments, assisted with the navigation of the social service system, and helped in making pertinent referrals to CBOs that provide supportive services. Peer support specialist also served as role models and shared information about and the use of coping skills, problem-solving techniques, and constructive social skills through coaching activities.
Assessment and documentation
The WCAP team used the care planning and coordination software previously described to record comprehensive behavioral health; medical, pharmacy, social, and health system assessments; the care plan; and outcomes related to the care plan. The software system, originally designed for behavioral health services, underwent extensive reprogramming to incorporate medical and general health factors that were needed for CIDP participation. In addition, licensed copies of the INTERMED-Complexity Assessment Grid (IM-CAG) assessment tool (Huyse, Stiefel, & de Jonge, 2006) and the Patient Activation Measures (PAM) tool were inserted. They were used as a part of the case management documentation process. The Patient Health Questionnaire (PHQ)-9 and 12-Item Short Form Health Survey (SF-12) assessments were already imbedded in the BHS software.
The WCAP team was the first in the United States to employ the electronic IM-CAG tool, as a part of the CIDP comprehensive integrated case management assessment. It provided an overall picture of risks and vulnerabilities in complex patients (Stiefel et al., 2006; Huyse et al., 2006). The IM-CAG assesses patients across 4 domains: biological, psychological, social, and health system and through 3 time frames: historical, current, and anticipated. Importantly, the IM-CAG assessment links barriers to improvement with actionable interventions and allows collaborative patient-manager development of a care plan on the basis of assessment findings (Kathol et al., 2010). With training in IM-CAG and integrated case management principles and methodology, care managers could assist patients with their most pressing issues and complex comorbid conditions without cross-disciplinary handoffs.
Training
The WCAP team received training in the use of CMSA Care Management Guidelines, motivational interviewing techniques (Prochaska et al., 1992), and CMSA Case Management Adherence tools. Extensive training was also given to integrated care managers and support staff through the CMSA Integrated Case Management Training Program (see http://www.cmsa.org) and use of The Integrated Case Management Manual: Assisting Patients Regain Physical and Mental Health (Kathol et al. 2010) in anchoring cross-disciplinary IM-CAG complexity scores, developing care plans based on assessment findings, the iterative management of cases, documenting outcomes, and following patients through the improvement process. Westchester Cares Action Program team seminars provided knowledge about medical, mental health, chemical dependency, and transportation and community resources available in Westchester County. In addition, staff was trained in how to address psychosocial issues, use effective street outreach, assist with housing resources, and maintain street and driving safety.
The care management process
The WCAP enrollment outreach process involved mailings, phone calls, feet to the street knocking on doors, and collaboration with CBOs. During the start-up phase of the project, the care coordination team members were outstationed to CBOs to facilitate contact with potential enrollees. When beneficiaries were located, appointments were set up to inform them about the benefits of enrolling. The team met with the potential enrollees (WCAP members, hereafter members) face to face wherever they were (in their homes, a local park, the library, a laundromat, or the local McDonald's).
When this contact was made, WCAP staff gave potential new enrollees a "welcome kit" and discussed its content. The welcome kit included information about WCAP services, program expectations, and the value to the potential enrollee. If the person showed interest, informed consent was obtained and a visit was scheduled to complete the initial assessment. Potential enrollees were given incentives, a $10 gift card at the time of signing, and another $10 gift card at the time of the initial assessment.
The entry assessment was comprehensive and included an IM-CAG, PAM, PHQ-9, and SF-12. On the basis of findings of the assessment, the care coordinator developed a mutually agreed upon patient-centered care plan. Although the DOH required that the care plan be completed within 90 days after assessment, WCAP care coordinators accomplished the process on average within 14 days. A copy of the care plan was given to the patient and the patient's primary care provider if the patient had one. The care plan addressed medical, psychological, social, and health system issues. For instance, typical care coordinator interventions may include the following:
* Helping the patient find a primary care provider and medical home.
* Directing the patient to a behavioral health provider.
* Providing assistance with a housing issue, such as referral to a housing attorney, accompanying the member to the housing authority, helping them complete a housing application, and/or accompany them to court.
Integrated care coordination as a part of the CIDP was intended to be longitudinal. The care coordinator and support personnel made regular weekly telephonic contact with each of his or her managed members. He or she checked on the member's status, did creative problem solving when needed, and made appropriate referrals for issues that come up. Face-to-face visits and reassessments by the care coordinators took place at least every 6 months to monitor progress or to adjust the care plan. If a member was hospitalized, there was a reassessment after clinical event, which could involve a new diagnosis related to the hospitalization, a new care plan as part of discharge planning, and follow-up with further reassessment.
The WCAP team coordinated their activities with those of the provider at every step. Westchester Cares Action Program key strategic alliances made an integrated system of care possible for program participants. An arrangement called "collaborative service planning" meant that WCAP augmented the services provided by existing case management programs while preventing duplication of service. Care plans also included recommendations from the patient's health care providers in an attempt to improve outcomes. Finally, the medical home and/or the patient's primary care provider received a copy of the care plan and were kept informed of progress achieved.
Analysis
Initial enrollment data and scores for currently enrolled members who had 2 or 3 assessments with the IM-CAG, PAM, SF-12, and PHQ-9 were analyzed. Summary statistics were reported with means and standard deviations (SDs) for normally distributed results and medians and interquartile ranges for scores that were not normally distributed. Normally distributed first and second assessment results were compared using paired sample t tests. For nonnormally distributed comparisons, the Wilcoxon signed rank test was performed. For patients who had 3 assessments, repeated-measures analysis of variance was performed. Findings were considered statistically significant at a P value of <.05. Analyses were done with STATA 10.1 statistical software (Statcorp LP, College Station, Texas).
PRELIMINARY RESULTS
Between the initiation of the CIDP in August 2009 and November 2010, the WCAP team received an original and 5 refresh lists containing a total of 943 names of potential enrollees. Of these, 758 were found to be eligible after review in the ePACES portal of the NYS eMedNY Medicaid Information Management System. The state's system used by providers to determine whether or not the patient is eligible for services (Figure 1). Only 186 of the 758 eligible could be found, contacted, and enrolled despite extensive sleuthing using provided phone numbers, addresses, and the names of practitioners or community workers who may know where the WCAP team could find them.
By November of 2010, the WCAP team had enrolled 264 patients but only 207 remained active (Figure 2). Fifty-seven members were disenrolled because they became a part of other management programs, joined a long-term care program, took up residence in a nursing home, were incarcerated, moved out of the catchment area, had emergency Medicaid coverage only, lost eligibility, became dual eligible, or died.
Complete baseline data were available for 162 members who had been enrolled, assessed, and remained enrolled at 14 months into the program. The average (SD) age was 53 (12) years with a range of 22 to 92 years. There were 82 women and 80 men. Twenty-six (16%) were white/Caucasian, 66 (41%) were black, 29 (18%) were Hispanic, 2 (1%) were of other race or ethnicity, and 39 (24%) did not provide race or ethnicity information. At the first assessment, 28 (17%) had unstable housing and 30 (18%) had no source of health care.
Eighty-nine of the 162 patients had 2 or more assessments. Significant improvements were seen on the IM-CAG and SF-12 psychological scores, but not for the PAM, the SF-12 medical, and the PHQ-9 scores (Table 1). Since few enrollees were found to be depressed on the PHQ-9 at baseline (median score 5 [nondepressed]), one would not have expected improvement in this parameter.
Twenty-three patients had 3 serial assessments with complete data. Only improvement on the IM-CAG was significant (Figure 3). At 15 months, 100% of those involved in the WCAP program reported having a source of health care compared with 64% at the first assessment.
CASE EXAMPLE
Candace, a 51-year-old single African American woman, is a good example of one of the integrated case management enrollees. The WCAP team found that she had diminished cognitive function evidenced by poor ability to retain information or to follow instructions. She had a history of alcohol and substance abuse and also resided in transitional housing. Candace had pronounced kyphosis, profound hearing loss, and a large (grapefruit size) nonmalignant mass on the lateral aspect of her neck. Her physical appearance resulted in a poor self-image, social isolation, and low self-esteem. She was reluctant to undergo recommended surgery because she had been told that her residence could not care for postoperative patients.
The WCAP team conducted an assessment and developed a care plan with Candace. They advocated to retain her permanent housing by arranging for visiting nurse services to handle postoperative care. They coordinated preoperative consultation visits and the surgery date. The peer support specialist accompanied her to physician visits to explain the information provided by the physician. She also accompanied Candace to the hospital for the surgery.
A nonmalignant lipoma was removed from the neck without postoperative complications. Since the surgery, Candace began feeling better about her physical appearance. Her mood improved and she had a greater sense of optimism, an improved future orientation, increased social interaction, and a brighter affect.
The WCAP team referred Candace to a counseling center for IQ testing, which revealed an IQ of 57, "mildly mentally retarded." This information was used to advocate for enriched services through the Office of Mental Retardation and Developmental Disability and to pursue supplemental security income benefits. Candace became more confident in her ability to navigate the health care system and independently obtained a new hearing aid with only telephonic assistance. A Safelink phone was obtained for her.
Candace moved to an independent rooming house with help from WCAP. She reestablished relations with her family in the South and visited them for a week. Candace is not currently using drugs or alcohol and attends Alcoholics Anonymous/Narcotics Anonymous. The WCAP team is currently assisting Candace pursue Section 8 housing, obtain her GED, and get vocational training. A drop in her IM-CAG score from 46 to 32 at 6 months reflects her improvements.
DISCUSSION
After 15 months, the WCAP CIDP has demonstrated that a well-trained team of nurse and social worker care managers, integrated care coordinator support staff, and a peer support specialist using a feet to the street approach to integrated care management can find, enroll, and coordinate care for complex high-risk, high-utilizing patients in a care management program. Perhaps the greatest challenge for the WCAP has been associated with the mechanics of introducing an integrated management program into the NYS health system.
Enrollment was a major challenge. From the beginning, there was a scarcity of potential enrollees and/or inaccurate or missing demographic information from the NYS-DOH. A large number of the eligible beneficiaries had been undomiciled making it challenging to locate and enroll new clients. Westchester Cares Action Program had to outreach to a range of providers, CBOs, homeless shelters, and drop-in centers in the Westchester area to get their support in locating and providing care for potential enrollees. Interestingly, although our program is focused on care coordination, we received pushback from some of the provider networks, which viewed the WCAP as a competitor. It took considerable discussion to convince them that integrated care management services were complementary with theirs and not competitive.
It is too early to indicate whether the actions of the care management team are having their intended effect; however, the significant changes in IM-CAG scores and SF-12 psychological scores are encouraging. Because of the lag in receiving claims data, it is premature to examine whether there were changes in utilization. Furthermore, the independent contractor hired by the NYS-DOH to collect information about a control group could not release it to project contractors at the time of this writing.
The experience of the WCAP project in identifying and overcoming challenges provides valuable lessons for organizations seeking to undertake integrated care management projects for similar high-risk Medicaid populations. An important first step is obtaining buy in from your organization's administrative management. The WCAP team had to sell Hudson/BHS management on undertaking a Medicaid FFS project in the environment of a company that provided Medicaid managed care services.
Recruiting and training a team to deliver integrated care management was also a major challenge. Nurses and social workers needed to be comfortable with the integrated "no handoffs" medical and behavioral model and with the feet to the street approach to enrolling and assessing disadvantaged patients. Training clinical professionals in both areas took effort and time. We were encouraged by the number of nurses and social workers who were eager to explore the integrated no handoffs model and who were open to retraining and to education on integrated case management. Nevertheless, it required 40 hours of independent study for all in reading and studying The Integrated Case Management Manual, participation in an intensive 2-day CMSA sponsored training course on integrated case management, and passing a final examination before a certificate of completion could be obtained for those performing integrated case management.
Finally, since there was a desire to use internal care management documentation software, it took time and effort to add medical information and DOH reporting requirement components to the BHS behavioral health software; to program in the ability to complete complexity assessments, including the IM-CAG; to build integrated care plans; and to document ongoing outcomes in patients being managed.
SUMMARY AND CONCLUSION
The WCAP team overcame numerous challenges and learned important lessons about launching an integrated care management program in the community. Our experience during the 4-month ramp-up period and in our first 15 months of operations demonstrates the feasibility of delivering feet to the street integrated care coordination to complex high-utilizing, high-cost Medicaid FFS clients. Preliminary data suggest that the program is altering barriers to health improvement of individuals participating. Hudson/BHS are so impressed with initial results of this type of feet on the street integrated care management model that they are replicating it for complex Hudson members not involved in the NYS grant. The new program called complete care began enrolling members in April 2010. It is Hudson's and BHS's hope that these 2 programs will help us meet their Triple Aim-healthier communities, more satisfied members and providers, and reduced spending for the state and ultimately the taxpayer.
REFERENCES