Best Practices in Medicaid – Wyoming
The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others’ successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates.Introduction
In July 2004, The Wyoming Department of Health Office of Health Care Financing EqualityCare Program launched the nation’s first comprehensive, total population health management program to its entire population of clients. Regardless of their health status, individuals and families covered by the State of Wyoming’s Medicaid insurance program (EqualityCare) are offered health management services depending on their level of health or psychosocial needs. The program prescribes to a holistic approach, wherein the person as a whole, not just the disease, is managed by a multidisciplinary team of clinicians. At the core of this program is the philosophy that clients must be an integeral component in improving or maintaining their health. The Wyoming Total Health program, Healthy Together!, provides the tools for clients to accomplish this goal.Some clients may require more complex case management, such as those who are being discharged home from a facility; others may need assistance in understanding the importance of preventative screenings. Health Coaches and Case Managers--nurses, social workers and licensed professional counselors—work to meet each clients’ needs. In addition, clinical staff draws upon a variety of subject matter experts, including physicians, registered dieticians, respiratory therapists, physical therapists, social workers, licensed mental health clinicians and behavioral psychologists, for assistance in supporting EqualityCare clients.
Chronic Illness Management
Clients with chronic illnesses, such as diabetes, asthma and heart disease, are engaged into the chronic illness management programs. There are six condition-specific programs within Healthy Together! that are offered to clients.These specific conditions have been targeted because they represent the most costly and prevalent conditions found in the Wyoming EqualityCare population. Clients engaged in one of the six programs receive a variety of interventions including educational self-care handbooks, newsletters, web-based education, remote monitoring tools and telephonic health management. A significant focus of the program is the ongoing telephonic assessment, education, monitoring and support provided by Health Coaches and Case Managers.
Our telephonic assessment and educational materials focus on the following key areas:
- The client’s understanding of their disease/condition
- Treatment plan adherence
- Early symptom identification and early treatment
- Routine testing and screening
- Medication usage and compliance
- Weight management and nutritional support for the client and family
- Activity/exercise
- Smoking cessation
- Managing complications
- Co-morbidity identification and management
Complex Case Management
Many clients within the Healthy Together! program require more intensive support and care coordination by Case Managers. This includes those who have been hospitalized and are discharging home; adolescent and adult clients diagnosed with complex behavioral health issues which require intensive care coordination between their families, providers and the community; clients diagnosed with breast or cervical cancer who we assist with coordinating benefits and care with the Wyoming Department of Health’s Breast and Cervical Cancer Early Detection Program; and infants in Wyoming or out of state neonatal intensive care units. Complex Case Management provides clients and families with:- Assisting with discharge planning
- Advocating for quality care and appropriate level of care/services
- Coordinating with providers to facilitate recovery and continuity of care
- Monitoring progress and treatment plans/options
- Facilitating communication with EqualityCare program staff
- Identifying community resources
- Educating and supporting clients and families
Wellness and Prevention Initiatives
In addition to providing chronic illness and complex case management, Healthy Together! provides all EqualityCare clients (regardless of their health status) with wellness and prevention information and links to community resources in an effort to avoid illness. Information provided to clients ranges from tips on how to manage weight and tools to quit smoking to the importance of being properly vaccinated and other ways to adopt a healthy lifestyle.1) Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)
The Real Choice Waiver:
A program open to adults and children with developmental disabilities or acquired brain injuries to strengthen supports so that people can live with their families or in a home of their own. The plan will be focused on the strengths, preferences and desired outcomes of the person and be self-directed. All resources available to the person can be used creatively to help them live the life they desire. A participant on this waiver shall have a strong support network, accept reduced funding in exchange for more choice, and not wish to live in a group or receive traditional agency services.
Main Components:
- Individual Budget – created after considering all income and resources available, related directly to support needs, and controlled by the participant and their freely chosen allies.
- Independent Support Broker – helps the person design, organize, and evaluate how plan is working, and truly works for and represents the individual without divided loyalties.
- Fiscal Intermediary – the place where the funding allocation for the individual budget is banked. They can write checks to pay bills, take care of tax withholding, pay workman’s compensation, health insurance, or other benefits. They can assist a person to recruit, screen, and hire support workers and act as the employer of record, if needed.
2) Delivering high quality, coordinated, long term care for the disabled and/or the infirm
Wyoming EqualityCare has several initiatives in providing long-term care for the disabled and the infirm:
- Waiver programs that offer community-based cost-effective services to clients who might otherwise seek costly nursing facility care.
- Support for individuals who are able to discharge from a nursing facility and receive necessary care in the community through Project Out. This includes providing living essentials, such as rent deposits, cooking supplies, etc.
- For those who have complex medical needs or chronic conditions, the Healthy Together! program provides disease and case management services.
- Post-discharge support for those clients returning home from an in-patient facility.
- For those with less acute needs, the health management program offers “wellness” programs, such as education on preventative screenings, such as mammograms and immunizations, smoking cessation and weight management support.
The State of Wyoming EqualityCare program utilizes many forms of health information technology (HIT) to facilitate management of its Medicaid populations:
- Upon identifying clients appropriate for the Healthy Together! health management program, health informatics tools to further analyze each individual’s claims data and stratify him/her according to current and predicted illness burden. Predictive Modeling identifies clients who are at risk for a particular disease state. Predictive Modeling analyzes historical medical, behavioral and pharmaceutical claims data using statistical algorithms that take into account all major disease diagnoses, since at-risk cases are generally comprised of multiple conditions. Individuals are identified who are at risk for intensive service utilization, but who have not yet had claims submitted for these services. Through outreach and early intervention, this approach serves to alleviate future suffering and to promote entry into service at a lower intensity of care. Additionally, utilizing the Johns Hopkins ACG Case-Mix System, claims data is used to sort a population into several health status categories to predict the population’s need for health services or their illness burden. Illness burden is a measure of a population’s sickness level or medical complexity; the more medically complex the population is, the greater the illness burden. Based on the determined illness burden, clients are assigned to a category called an adjusted clinical group (ACG). The premise behind the assignment is that clients assigned to an ACG should use a similar amount of healthcare resources. ACGs identify and stratify by risk those members with behavioral and medical conditions who would benefit from health management education and interventions.
- The Healthy Together! program utilizes telemedicine technology to assist in the care management of the high-risk chronically ill clients. “Health Buddy”—a remote telemedicine monitoring solution which plugs into client’s home phone line—collects symptomatic and behavioral information and vital signs from the clients on a daily basis. The information is then transmitted to the client’s Health Coach/Case Manager who analyzes their clients’ conditions, determines if they may be at risk of complications and relays the information to clients’ treating physicians/providers if necessary. The goal of Health Buddy is to enable clients to participate in their own care by answering diagnosis-specific questions on a daily basis, while receiving targeted education about their condition in order to modify behavior for improved outcome.
- The Wyoming EqualityCare Medicaid Management Information System (MMIS) has the ability to accept electronic claims and make payments by electronic fund transfer for all provider types. In addition, providers have access to a web-based, HIPAA-compliant portal that enables them to:
- Download Medicaid paid claim data submitted for a patient by any provider over the past 2 years (drug claims, diagnosis codes, CPT codes, etc.)
- Identify clinical issues that affect the patients’ care.
- Determine if a drug is a preferred agent or requires edit override.
- Prospectively examine how specific Preferred Drug List (PDL) and Clinical Edit criteria would affect a prescription for an individual patient and determine if a prescription meets the program’s requirements for payment.
- Electronically request a Prior Authorization (PA) or Clinical Edit override.
- Identify existing approved or denied Prior Authorizations or Clinical Edit overrides issued for a patient.
- Receive prescribing alternatives and best-practices information.
- Transmit a prescription electronically to the recipient’s pharmacy of choice via a switch vendor or fax.
- Download Medicaid paid claim data submitted for a patient by any provider over the past 2 years (drug claims, diagnosis codes, CPT codes, etc.)
In the State of Wyoming there are several ongoing initiatives addressing the states health care needs. These include the Wyoming Health Care Commission (WHCC), and the Governors Task Force on Health Information Technology. The WHCC has identified 6 priority areas for improving access to and delivery of Healthcare in Wyoming. These are:
- Pursue incremental steps to reduce the number of uninsured individuals, while pledging to ultimately make certain that all Wyoming residents have some form of health insurance coverage.
- Maintain a stable supply of health care professionals to support primary and secondary care.
- Promote the integration of healthcare services for purposes of affordable patient-centered care.
- Strengthen Wyoming’s data infrastructure to improve the delivery of healthcare services.
- Improve population health and reduce the number of uninsured through emphasizing collaborative planning and individual responsibility.
- Develop a new system to address and resolve healthcare errors to improve patient safety in the state of Wyoming.
The Wyoming Dept of Health has long identified the same problems and has been developing a program that we feel offers a potential solution to many of these needs. This project, the Total Health Record (THR) will combine a Patient Centered Medical Home (PCMH), with Pay-for-Participation (P4P) and an HER, and will be web-based. While the main goal from the Department standpoint is to assist our Medicaid clients and providers, we feel this has the potential to expand to become a multi-payer program. Specifically we are designing this program to give us measurable improvement in utilization of preventative medicine (vaccines, cancer screenings, disease management counseling, etc), decrease inappropriate ER/hospitalization rates, achieve goals in the management of chronic disease, and make readily available to providers standardized information such as a patients medication list, diagnoses, evidence-based guidance and protocols by conditions or co-morbidities, and allergies, all of which will enhance patient safety.
THR Background
The THR began over 1 year ago, as the WDH recognized that the current delivery model of Medicine was not living up to the capabilities currently available in the 21st century. It was not that our providers were not intelligent or motivated enough, but rather that the new technology was not being harnessed by them to assist in providing the best preventative care and treatment of chronic conditions, and to decrease catastrophic illness and hospitalization. This was leading towards higher costs, both to the State in terms of greater financial expenditures for ER and hospital visits, and to the people of Wyoming in terms of sub-optimal health outcomes. The THR was designed with three central elements; Pay for Participation (P4P), the Patient Centered Medical Home (PCMH) and the electronic Health Record (EHR), in sum, a Continuum of Care record.
- Pay for Participation: this component will increase the provider’s role in managing the health of clients by providing incentives to medical professionals for providing and reporting of certain services and protocols recommended in evidence-based guidelines
- Medical Home/PCMH: this component encourages a primary care physician relationship; where clients will have a “medical home” model whereby the primary care physician will develop a plan of care for each client and help the client to actively manage their health care.
- Electronic Health Record: clients, the healthcare team, and the State Medicaid Agency will be able to access a range of information pertaining to a client’s health, treatment plan, and conditions from a variety of sources, such as claims data, preventive health information from providers, pharmacy data, case manager notes and assessments, quality performance indicators, and disease monitoring data from health coaches.
The WDH has purchased a product called CyberAccess through our fiscal agent ACS. This module assists medical professionals with the prior authorization program through SmartPA. A recent upgrade in the CyberAccess program brings within functional capability the goals of our THR, should we choose to expand those capabilities.
CyberAccess:
- Is web-based, so that any provider with modem capabilities could use it, thereby alleviating enormous expenditure on the physician’s part and allowing for uniformity in programs. It would be compatible with most existing EHR’s and would use standard interface technology.
- It is integrated with our payment system, so eventually providers will only have to submit their encounter data one time both to receive payment for service and to submit data to the THR simultaneously.
- Patient tracking and registry functions will enable the provider to best manage clinical conditions, which facilitates optimal care and ensuring that sure patients are meeting practice guidelines.
- Chronic Disease management will allow optimum management of these conditions, further reducing complications and hospitalizations.
- There is a “cover sheet” which enables providers who access it to see a current list of diagnoses, allergies, current medications, recent procedures. These fields are populated off of claims data, so they are current and the same from service location to another location, decreasing the chance for medication errors.
- Electronic prescribing can be accomplished, and providers benefit from real time prior authorization, knowing which prescriptions are on formulary and where there is potential for an adverse drug interaction.
- Laboratory tests and diagnostic test results can be entered directly from the lab or added via optical scanner and tracked over time.
- Patients can also view their own pages, thereby making it a Personal Health record (PHR). They will be able to review their Plan of Care in lay terms, look up information on their condition and prescription drugs, correspond with their healthcare team, and document items such as blood sugar, blood pressure, weight, etc.
- The physician and his staff can help to coordinate client care, scheduling tests and consults and providing direct communication between offices. Also, wherever the patient goes, any provider, with the patients’ permission could access the site, saving valuable time in emergencies.
- Finally, this system is capable of expanding to multiple payers. Therefore, not only could Medicaid use it, but also CMS (Medicare), Blue Cross/Blue Shield and Great West. The WDH would anticipate turning over a multipayer system to WHIO to operate. Each payer could pay a proportionate share of the operating expense, based upon the number of enrollees in the system.
We do not feel this is the only solution, nor will it cure every concern within the medical care system. We do feel this is an exciting opportunity to harness the electronic capability now available, and if successful, save the State significant costs. It has the capacity to bring together many simultaneous efforts underway within the state.
4) Transparent and publicly-accessible measurements of patients’ outcomes and/or quality improvements
The Wyoming EqualityCare program provides access to outcomes and data on the total population health management program, MMIS activities and other initiatives through several venues. The Healthy Together! program includes outreach to local and state media and other healthcare stakeholders through a comprehensive public awareness campaign. This effort is designed to reach clients and those members of the community who are also working with EqualityCare clients to educate them about the importance of prevention and screening for illness and practicing healthy behaviors. Information such as disease prevalence within the Medicaid population, successful cases and cost outcomes are shared with media, state legislators and other stakeholders.
Transparency also occurs with the sharing of program outcomes and improvements with numerous Wyoming Department of Health provider and community partners. Transparency fosters coordination of provider and client education initiatives, and helps build capacity within the communities where EqualityCare clients live. Within Wyoming’s new Pay for Participation (P4P) program providers will soon have access to patient-level and practice-level data on certain services and protocols recommended in evidence-based guidelines which will improve their ability to manage the health of their patients.
5) What are your future plans?
Expansion of the Wyoming EqualityCare program in 2008 includes the following initiatives:
- Implementation of the Total Health Record, which will give clients and the entire provider team access to a broad range of intelligent data regarding the client’s health conditions, meaningful prevention and maintenance information, and access to other health care professionals. This will be coupled with the growth of the P4P incentive program.
- Focus specialized nurse Care Team members to address elderly/long-term care clients with focus on hospital/home assessment, client goal-setting, development of self-care skills, care planning for geriatric issues; clients identified with polypharmacy issues; and children diagnosed with childhood obesity.
- Continue to use Lay Health Educators, senior companions or foster grandparents to help educate clients on wellness issues. Consider expanding LHE model into the community to extend education into long-term care facilities, senior centers, home-bound clients and other hard-to-reach clients.
- Expand the use of Gap Analysis tools to identify clients for intervention. Similarly, utilize provider/facility profiles that include the ER and hospitalization rates for clients, adherence to clinical indicators by clients, gaps in LTC care practices, i.e. wounds, falls, etc. Deliver a client profile to appropriate providers that include a detailed look at the client including their ER usage, diagnosis related to ER visits, prescriptions filled, and notation if the client has been engaged into Healthy Together!
- Utilize health literacy techniques to enhance action plans used with members for self-management, printed material, audio tools (DVDs/CDs), new waiting room posters, etc. In addition, refine educational fact sheets with a focus on benefits of Wyoming EqualityCare and Medicare coverage for dual eligible clients. Utilize client incentives to encourage the attainment of plan of care goals specific to wellness/disease conditions (i.e. water bottles and pedometers for clients identified with prediabetes, hypertension, obesity; stress balls, books/magazines, t-shirts for others).
- Support the expansion of telehealth and telepsychiatry initiatives for the delivery of care to rural clients.
- Provide business office best practice support to physicians and their staffs. Activities may include providing DM/chronic care model training; providing grants encouraging innovative practice improvements; providing reimbursement for provides to attain NCQA certification; and providing “practice management/QI” assistance on implementing evidence-based guidelines into EHRs.
