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Managing Chronic Managing Chronic Illness in a Medicaid Illness in a Medicaid

Population ~ Population ~

The Indiana Chronic The Indiana Chronic Disease Management Disease Management

ProgramProgram December 2, 2004December 2, 2004

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Chronic Disease ObjectivesChronic Disease Objectives– Provide consistently high quality care to Medicaid Provide consistently high quality care to Medicaid

recipients that improves health status, enhances quality recipients that improves health status, enhances quality of life and teaches self management skills. of life and teaches self management skills.

– Reduce the overall cost of providing health care to Reduce the overall cost of providing health care to Medicaid patients suffering from chronic diseases.Medicaid patients suffering from chronic diseases.

– Provide support to primary care providers and integrate Provide support to primary care providers and integrate primary care with case management.primary care with case management.

– Utilize and strengthen the public health infrastructure.Utilize and strengthen the public health infrastructure.

– Achieve long term results by changing the way primary Achieve long term results by changing the way primary care is delivered across the state, not just for Medicaid.care is delivered across the state, not just for Medicaid.

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• MakeMake– Develop “in house”, typically as part of Primary Care Case Develop “in house”, typically as part of Primary Care Case

Management (PCCM) programManagement (PCCM) program

• BuyBuy– Outsource to commercial vendor Outsource to commercial vendor

– Purchase chronic illness software systemPurchase chronic illness software system

• AssembleAssemble– Hybrid approachHybrid approach

– State may purchase key components but state retains control of State may purchase key components but state retains control of the programthe program

State Options: State Options: Make, Buy, AssembleMake, Buy, Assemble

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• One Stop Shopping (Commercial DM vendor)One Stop Shopping (Commercial DM vendor)

• ““Guaranteed” savingsGuaranteed” savings

• Difficult to negotiate risk for Medicaid populationDifficult to negotiate risk for Medicaid population

• Jobs & revenue associated with running the program go out of Jobs & revenue associated with running the program go out of statestate

• Focus tends to be on telephonic case management Focus tends to be on telephonic case management

• Little or no local input/experienceLittle or no local input/experience

• Difficulties interacting with claims systems, makes reporting Difficulties interacting with claims systems, makes reporting duplicativeduplicative

Advantages/Disadvantages: BuyAdvantages/Disadvantages: Buy

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• Allows for local input and experience Allows for local input and experience

• Focus is on provider/patient relationshipFocus is on provider/patient relationship

• Keeps revenues and jobs in stateKeeps revenues and jobs in state

• Creates a comprehensive, sustainable locally based infrastructure Creates a comprehensive, sustainable locally based infrastructure with effective case management in place to support primary care with effective case management in place to support primary care providers and Medicaid membersproviders and Medicaid members

• Requires significant state resources Requires significant state resources

• State retains financial riskState retains financial risk

• TimeTime

Advantages/Disadvantages: Advantages/Disadvantages: Make/AssembleMake/Assemble

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Indiana Approach: AssembleIndiana Approach: Assemble• Why?Why?

– NGA Chronic Disease Policy AcademyNGA Chronic Disease Policy Academy

– Strong Department of Health LeadershipStrong Department of Health Leadership

– Interested & Dedicated Local PartnersInterested & Dedicated Local Partners

– Change the way care is delivered statewideChange the way care is delivered statewide

• Chronic Care ModelChronic Care Model– Ed Wagner & Team of National Experts (MacColl Institute, Institute Ed Wagner & Team of National Experts (MacColl Institute, Institute

for Healthcare Improvement)for Healthcare Improvement)

– Evidence based interventions with proven resultsEvidence based interventions with proven results

– Promotes patient self managementPromotes patient self management

– Carries over to improve care for all patients in a practiceCarries over to improve care for all patients in a practice

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• Creates a comprehensive, sustainable Creates a comprehensive, sustainable community based infrastructurecommunity based infrastructure

• Connects care management & primary careConnects care management & primary care

• The ICDMP infrastructure supports chronic The ICDMP infrastructure supports chronic care, quality improvement efforts statewide – care, quality improvement efforts statewide –

for all patients, providers, payers and for all patients, providers, payers and disease statesdisease states

Indiana Chronic Disease Management Indiana Chronic Disease Management Program Key PrinciplesProgram Key Principles

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• Program ManagementProgram Management. . Medicaid and Health are jointly responsible for the program including policy development, contracting and monitoring performance.

• Primary CarePrimary Care. . The focal point of patient care is the primary care physician. Key elements of the Indiana CDM program are designed to provide information & resources to support the physician.

• Care ManagementCare Management. . Care management is comprised of:

– A Call Center that monitors patient status and follow-up based on the established protocols.

– A Nurse Care Manager network whose nurses provide more intense follow up and support to high risk patients.

• Patient Data RegistryPatient Data Registry. . An electronic data registry is available to physicians and can be used for all patients. For Medicaid patients, it is populated with claims data and case management data.

• Measurement & EvaluationMeasurement & Evaluation. . Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention & control group.

Main Program ComponentsMain Program Components

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Program Components: Client Flow Program Components: Client Flow

Community Resources

Self Management

Training

Nurse Case Management 15 - 20% of

Patients Web-Based Patient Registry

Chronic Care Model Collaborative Training

Decision Support

Call Center 80 - 85% of

Patients

Patient Provider

Measurement & Evaluation:Randomized Controlled Trial & Overall Statewide Evaluation

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ICDMP StatusICDMP Status

• Disease States: Disease States:

– Current: Diabetes, Congestive Heart Failure, AsthmaCurrent: Diabetes, Congestive Heart Failure, Asthma

– Future: Stroke/Hypertension, HIV/AIDSFuture: Stroke/Hypertension, HIV/AIDS

• Implementation: Phased In StatewideImplementation: Phased In Statewide

• Evidence Based Guidelines: Statewide DisseminationEvidence Based Guidelines: Statewide Dissemination

• Chronic Care Collaboratives: 3 Regional CollaborativesChronic Care Collaboratives: 3 Regional Collaboratives

• Measurement & EvaluationMeasurement & Evaluation

– Monthly reporting – sample mandatory measures:Monthly reporting – sample mandatory measures:

– Design & implementation of randomized controlledDesign & implementation of randomized controlled trial trial

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Percent of patients achieving:Percent of patients achieving:

August ’03August ’03 June ‘04June ‘04

• HbA1c < 8HbA1c < 8 28.7%28.7% 59%59%

• Self Management GoalsSelf Management Goals 36.8%36.8% 57.2%57.2%

• Blood Pressure <130/80Blood Pressure <130/80 20.6%20.6% 28%28%

ICDMP Accomplishments To Date ICDMP Accomplishments To Date

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Challenges & Lessons LearnedChallenges & Lessons Learned• Provider buy-in Provider buy-in

• Incentives: providers, recipients, partners/vendorsIncentives: providers, recipients, partners/vendors

• Integration with Managed Care Organizations (MCOs)Integration with Managed Care Organizations (MCOs)

• DataData

– Administrative vs. Clinical Administrative vs. Clinical

– Entry & ReportingEntry & Reporting

• Cost savings / Return on InvestmentCost savings / Return on Investment

• Medicare Modernization Act – Part DMedicare Modernization Act – Part D

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Critical Success FactorsCritical Success Factors

• NGA Policy Academy & ResourcesNGA Policy Academy & Resources

• Technical Assistance from National ExpertsTechnical Assistance from National Experts (MacColl Institute, Institute for Healthcare Improvement, Center for Health Care Strategies, (MacColl Institute, Institute for Healthcare Improvement, Center for Health Care Strategies,

National Initiative for Children’s Healthcare Quality)National Initiative for Children’s Healthcare Quality)

• Chronic Care Model FoundationChronic Care Model Foundation

• Integration of Health & Medicaid Integration of Health & Medicaid

• Legislative SupportLegislative Support

• CMS SupportCMS Support

• Long Term View…..short term investmentLong Term View…..short term investment

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ICDMP ResourcesICDMP Resources

For More Information, such as For More Information, such as

•Provider Toolkit & GuidelinesProvider Toolkit & Guidelines

•Patient Self Management & Education Patient Self Management & Education

•Training MaterialsTraining Materials

http://www.indianacdmprogram.com/