Chapter 22

The SoonerCare Health Management Program

Carolyn J. Reconnu and Mike Herndon

Introduction

The SoonerCare Health Management Program (HMP) is an ongoing quality improvement initiative aimed at improving the lives of Oklahomans with chronic disease as well as reducing future incidence. The SoonerCare HMP was developed in response to the Oklahoma Medicaid Reform Act of 2006. The Reform Act mandates resulted from the task force developed by the Oklahoma Legislature, whose mission was to identify $100 million in savings through efficiencies to the Medicaid system. While the task force findings overall were positive, one element of this legislation required the Oklahoma Health Care Authority (OHCA), Oklahoma’s single-state agency for Medicaid administration, to create a disease management program to improve quality of care and reduce the cost of care for those with chronic conditions. This recommendation supported OHCA’s stated mission to purchase state and federally funded health care in the most efficient and comprehensive manner possible, and to study and recommend strategies for optimizing the accessibility and quality of health care.

After consulting with local and national industry experts in disease management principles and programs, the OHCA used the Chronic Care Model (Wagner 1998) as a basis to create the SoonerCare HMP. A guiding principle of the Chronic Care Model is to pair an informed and activated patient with a prepared and proactive provider in order to create the best possible health outcome. The SoonerCare HMP addresses both of these key components, which optimizes sustainability. OHCA partners with a vendor, determined through competitive bid, to operate the program. Our vendor, Iowa Foundation for Medical Care (IFMC), initiated services to our SoonerCare members and providers in February 2008.

The HMP program

Nurse Case Management

The HMP program comprises two primary components: Nurse Case Management and Practice Facilitation. Nurse case management in our program emphasizes self-management principles and is provided for up to 5,000 of our highest risk members. SoonerCare had approximately 500,000 members in the adult and children categories at the time the HMP was being developed, with about 20% having a chronic disease. It was estimated that 5% or less of our members spend 50% or more of our Medicaid dollars. Therefore, the determination was made to serve our top 5% highest risk members with chronic disease, or 5,000 members, through concentrated case management efforts.

These highest risk members are identified with predictive modeling software that utilizes a sophisticated approach to trend episodes of care and treatment groups to evaluate current gaps in care and future risk. The first 1,000 of these members at highest risk (Tier 1) are provided face-to-face nurse case management. The remaining 4,000 high-risk members (Tier 2) are provided telephonic nurse case management. Both tiers of members receive comprehensive health status, health literacy, behavioral health, and pharmacy assessments. At a minimum, on a monthly basis, either face-to-face or telephonically, the HMP nurses work with individual members on goals directed at their transformation to a more informed and engaged patient. This work includes a strong educational component, as well as increased access to community resources. The HMP nurses work to involve the primary care provider (PCP) in their care plan and keep them apprised of the member’s progress. To date, approximately 10,000 SoonerCare members have been served by this program.

Patient example

An example of the success of the SoonerCare HMP is Robert B, age 41. Robert has type 2 diabetes, congestive heart failure, hypertension, hyperlipidemia, obesity, and non-organic psychosis. Robert accepted our offer of case management in August 2008. At that time, he qualified as a Tier 2 member to receive telephonic nurse case management. He was transferred to Tier 1 in March 2009 for more intensive and personal involvement due to his high level of need. At the time of enrollment to our program, Robert smoked ten cigarettes per day and led a sedentary lifestyle. A diabetic diet had been recommended by his physician but he did not follow the dietary guidelines because of lack of knowledge. After working with his HMP nurse case manager and with supervision of his primary care provider, Robert adopted an 1,100 calorie per day diet, lost 89 pounds in one year (going from 309 to 220 lbs) quit smoking, and started an exercise program. His hemoglobin A1C went from 7.3% to 5.2% in 16 months. He achieved decreases in his total cholesterol from 129 mg/dL to 98 mg/dL and his triglyceride levels decreased from 249 mg/dL to 127 mg/dL.

From a cost-savings perspective, impact is also realized utilizing predictive modeling profiles. After five months in the case management program, a consistent positive variance was demonstrated between Robert’s forecasted cost for an upcoming year and the actual cost expenditures for that same year. This cost variance, which ranged from 1.7% to 13.6%, has been sustained over the six months of currently available data.

Practice facilitation

The other key component to the SoonerCare HMP is the necessary support to assist the primary care provider in becoming more prepared and proactive. This component is commonly known as practice facilitation. Within our program structure, the practice facilitators are specially trained nurses working as free consultants who help providers improve their office efficiency and identify methods to improve the quality of care. The SoonerCare HMP incorporated this key support for practitioners to enhance the sustainability of the program. We have found that a fundamental element is assistance in developing structured policies and procedures, formal job descriptions, and a team-centered environment. For an office to function efficiently, all team members must fully understand their roles in the various processes and procedures that comprise daily workflow. Increased definition and structure of the office environment enhances the team members’ confidence in their various roles, which diminishes turnover rates and enables the team to function more effectively.

Once the foundation is in place, the practice facilitator conducts a comprehensive assessment of the practice. The practice is asked to conduct a self-assessment, while a chart data abstraction is performed by the practice facilitator. The comparative results of these two components are shared with the practice for a baseline understanding of the current trends in care gaps and patient outcomes. Attention is given to staff capabilities regarding comprehension of quality improvement principles. Office dynamics, including interpersonal communication, clinic paradigms and culture are evaluated. Educational needs and learning styles are assessed.

Clinic processes are mapped to analyze pain points in workflow. To further target improvements in chronic disease care, the practice facilitators expand process mapping to look at specific disease associated care opportunities in relation to standards of care. The facilitators evaluate any quality or process improvement initiatives in which the practice is currently participating. This is critical to determine if competing priorities and initiatives will divert the clinical staff’s attention. It is possible for some clinics to participate in more than one quality improvement initiative, but it is optimal for an interface to exist between quality projects.

Once the practice facilitator formulates a strong understanding of the clinic’s needs, they assist with identification and prioritization of specific process improvement interventions, whether these are general workflow issues or specifically related to care gaps and missed opportunities. Specific evidence-based interventions are considered if this need is identified.

The facilitators further support practice efforts by providing targeted education to staff regarding disease processes and process improvement principles. They work with the practice to implement regular meetings in an effort to sustain staff interest and foster continued learning related to the initiative.

Facilitators assist practices with the implementation of an electronic health management information system or patient registry. This web-based tool allows the practice to enter member data to track over time so that each member receives all the appropriate tests and treatment recommended for their chronic condition(s). The registry contains disease modules on coronary artery disease, hypertension, diabetes, heart failure, asthma, tobacco cessation, preventative care, and asthma. The facilitators assist with the electronic health management system and/or disease registry implementation by front-loading the data for all patients in the practice with a chronic disease, who were identified with predictive modeling software.

Other process improvement opportunities include utilization of standing orders to improve clinic efficiency and referral tracking. The practice learns how to run reports that highlight individual patient-care gaps in addition to reports that assist with overall population management.

Once the basic components of practice facilitation are applied, more advanced patient-centered principles are introduced. These may include development and deployment of a patient education or community resource library, implementation of behavioral health screening and instruction in motivational interviewing.

Practice facilitation services have been provided to over 75 Oklahoma-based practices to date, indirectly benefiting almost 90,000 SoonerCare members. While a comprehensive evaluation of the effectiveness is ongoing, review of data for three practices with solid adoption of the registry and related process improvement efforts notes a significant savings. The forecasted cost of the panel members was averaged and compared to the actual cost of their panel members a year later, revealing a 7.2 to 11.3% positive variance. When the average savings are distributed over the entire panel, this equates to $448,000 to $772,000 in savings for each of the three practices.

As the SoonerCare HMP was developed, a strong nurse case management component was expected by the authors of the legislation. OHCA supported this expectation but expanded the program even further to assist practitioners in their efforts to care for their patients. The initial indication is that both nurse case management and practice facilitation are effective methods to improve individual health outcomes and the quality of care delivered to patients. As the SoonerCare HMP matures, we realize there are opportunities for blending the practice facilitation and nurse case management activities more closely together. Contractual and state purchasing guidelines have kept us from a rapid cycle change in our HMP structure, but new models that would blend our two current HMP roles capture our interest as we look to future redesign options. Providers indicate that incorporating nurse case management into their practice would save them time and allow them to avoid missed care opportunities. We are working to strengthen the nurse case managers’ relationships with the practices until more fundamental changes can be made.

Future directions

The SoonerCare HMP is into the third year of a five-year contract. An independent evaluator, Pacific Health Policy Group, provides an objective review of the program on a yearly basis. Evaluator feedback serves to guide program changes to better meet the needs of our high risk members and their providers.

Similarly, we work to respond to newly developed programs and initiatives, both internal and external. The SoonerCare HMP staff work collaboratively with key parties on current federal initiatives such as the Medicaid EHR (electronic health record) Incentive Program and Section 2703 (health homes) of the Patient Protection and Affordable Care Act. We also work to adapt our processes to support the newly adopted patient-centered medical home (PCMH) payment structure and development of health access networks (HAN) within the Oklahoma SoonerCare program. These developing programs provide unique opportunities for adaptation and continued growth of the SoonerCare Health Management Program.

Reference

Wagner, E.H. (1998) Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice, 1(1): 2–4.