Centene Corporation ®, Nurtur ®, Managed Health Services
Let the Data Guide Program Planning, Design and Implementation
Recognizing that many MHS members with asthma experienced disproportionately poor asthma outcomes, MHS developed an asthma disease management program to reduce the impact of asthma on its members. The MHS Asthma Program is designed to ensure members with asthma are connected to a medical home and primary care provider; and receive age- and culturally-appropriate asthma education, medication compliance support and social and environmental supports to help manage factors that exacerbate asthma. The program’s goals include reducing unplanned asthma-related healthcare utilization, reducing symptom severity and frequency and promoting compliance with self-management and medication guidelines outlined in NAEPP EPR-3. To achieve its goals, the MHS Asthma Team—which includes health plan case managers, the plan’s medical director and a disease manager or health coach from Nurtur—tracks and stratifies members with asthma according to risk. The team delivers risk-appropriate asthma education, home-based interventions with licensed Respiratory Care Practitioners and offers care support—such as transportation to clinical visits or help with electricity for nebulizers if their electricity is turned off. The Asthma Team also promotes strong relationships between patients and clinical providers and helps providers deliver guidelines-based care by sharing information collected through case management with providers and offering in-clinic national guidelines education for providers. All these mechanisms allow the Asthma Team to function as an extension of the primary care practice to reinforce the personalized asthma management plans jointly developed by providers and patients, and to provide real-time documentation of patient condition and compliance with the care plan. The Asthma Team also leads MHS’ collaborations with community organizations to integrate asthma care improvement within broader community health efforts. For example, MHS partnered with the Marion County Health Department, the Asthma Alliance, the American Lung Association and Improving Kids Environment to provide free lead testing, radon test kits, trigger locks and asthma educational materials and supplies through a Healthy Homes Spring Cleaning event.
Use Data to Demonstrate Your Program’s Value — Demonstrate Your Program’s Impact
The MHS evaluation program is specifically designed to track metrics that support continuous improvement of the asthma care program. This evaluation capacity is key to the program’s sustainability. Based on data demonstrating decreases in unplanned healthcare utilization (reduced ER visits and hospitalizations), MHS estimates its asthma case management program saves approximately $250,000 per year. While it is difficult to estimate the savings its environmental management program delivers, MHS conservatively estimates the environmental component of the program contributes 20% of the cost savings, or $50,000.
Use Data to Demonstrate Your Program’s Value — Demonstrate the Need for Your Program
The MHS Asthma Team and business leadership is cognizant of the particular needs of its Medicaid population and the significance of the environmental factors and socioeconomic barriers Medicaid patients often encounter when attempting to manage their asthma. MHS and Centene are committed to internally funding the comprehensive Asthma program, especially the telephonic and in-home environmental education program and efforts to coordinate with community-based resources to manage environmental factors contributing to MHS members’ asthma. Support for the program starts with the CEO, the health plan presidents and lead doctors and nurses in each market.
Furthermore, because it serves a Medicaid population, MHS believes the healthcare quality improvement story alone is worth the expense associated with the program. MHS has increased its HEDIS scores for appropriate asthma medications usage, has promoted the concept of a medical home for optimal asthma disease management and has improved vaccination rates in this high-risk population, resulting in better health outcomes at lower costs.
INTEGRATED HEALTH CARE SERVICES — FACILITATE COMMUNICATION ACROSS THE CARE TEAM
MHS uses IT systems to share information across the care team to improve member self-management, inform clinical care and promote care consistency. For example, members identified as medium-and high-risk for healthcare utilization may receive personal visits to assess factors that impact severity, such as the home environment, and reinforce self-management lessons. Home visitors complete spirometry screening and pulse oximetry, monitor vital signs, review medication plans and compliance and demonstrate tools, such as peak flow meters. When appropriate, home visitors suggest revisions to treatment plans and ask primary care providers to review and sign off on proposed changes. Home visit data is captured in centralized software and made available to the entire care team thereby supporting improved stratification and personalized treatment planning. The care team also convenes weekly ‘High Needs Rounds’ where case managers and the Asthma Team discuss members with particularly difficult to manage asthma.
Asthma Team members are trained in guidelines-based care and contact providers immediately if they note discrepancies between the treatment plan and the guidelines. Treatment plans are captured in a centralized system and can be seen by the entire MHS care team. Asthma Team members regularly review the treatment plans developed by the provider and patient to ensure patients understand and can follow their plans. Asthma Team members then share with the clinical providers any knowledge deficits observed related to the plan, pathophysiology, medication use or environmental management. Progress notes are faxed to providers at a minimum of six and 12 month intervals.
MHS prioritizes education and counseling on environmental asthma management. All members receive low-literacy environmental trigger educational materials; and environmental management through newsletters, and during telephonic case management and home visits. Members in the medium-and high-risk strata can receive home visits and environmental assessments, which include counseling on trigger management by respiratory therapists. Members who need them are connected to support resources, like smoking cessation, and the plan provides housing assistance, a critical resource for its Medicaid population. The Asthma Team also connects plan members with free community resources such as hypoallergenic pillowcases and mattress covers, fans and air conditioners. Finally, the Asthma Team works with clinical providers to share information from home assessments and deliver environmental education during clinical visits.
MHS monitors the asthma program through a continuous Quality Management/Quality Improvement Program to determine its clinical and financial impacts. This information allows MHS to continuously improve asthma health outcomes, and increase program effectiveness. A 2007-2009 study assessed the program’s impact on health outcomes and treatment costs using medical and pharmacy claims data for children (n=3,986) and adults (n=1,238). For child participants (compared against a non-participant matched control group), the program reduced ER visits by 17.3% and lowered inpatient admissions by 28.6%; increased scheduled visits to primary care providers by 11.1%; and increased vaccination rates by 22.5%, indicating improved preventative care. For adult participants (compared against a non-participant control group), ER visits were reduced by 9.4%, while visits to primary care providers increased by 16.4% and vaccination rates increased by 51.3%.