Managing Chronic Illness in a Medicaid Population ~

1. Managing Chronic Illness in a Medicaid Population ~ The Indiana Chronic Disease Management Program December 2, 2004

2. Chronic Disease Objectives • Provide consistently high quality care to Medicaid recipients that improves health status, enhances quality of life and teaches self management skills. • Reduce the overall cost of providing health care to Medicaid patients suffering from chronic diseases. • Provide support to primary care providers and integrate primary care with case management. • Utilize and strengthen the public health infrastructure. • Achieve long term results by changing the way primary care is delivered across the state, not just for Medicaid.

3. State Options: Make, Buy, Assemble • Make • Develop “in house”, typically as part of Primary Care Case Management (PCCM) program • Buy • Outsource to commercial vendor • Purchase chronic illness software system • Assemble • Hybrid approach • State may purchase key components but state retains control of the program

4. Advantages/Disadvantages: Buy • One Stop Shopping (Commercial DM vendor) • “Guaranteed” savings • Difficult to negotiate risk for Medicaid population • Jobs & revenue associated with running the program go out of state • Focus tends to be on telephonic case management • Little or no local input/experience • Difficulties interacting with claims systems, makes reporting duplicative

5. Advantages/Disadvantages: Make/Assemble • Allows for local input and experience • Focus is on provider/patient relationship • Keeps revenues and jobs in state • Creates a comprehensive, sustainable locally based infrastructure with effective case management in place to support primary care providers and Medicaid members • Requires significant state resources • State retains financial risk • Time

6. Indiana Approach: Assemble • Why? • NGA Chronic Disease Policy Academy • Strong Department of Health Leadership • Interested & Dedicated Local Partners • Change the way care is delivered statewide • Chronic Care Model • Ed Wagner & Team of National Experts (MacColl Institute, Institute for Healthcare Improvement) • Evidence based interventions with proven results • Promotes patient self management • Carries over to improve care for all patients in a practice

7. Indiana Chronic Disease Management Program Key Principles • Creates a comprehensive, sustainable community based infrastructure • Connects care management & primary care • The ICDMP infrastructure supports chronic care, quality improvement efforts statewide – for all patients, providers, payers and disease states

8. Main Program Components • Program Management. Medicaid and Health are jointly responsible for the program including policy development, contracting and monitoring performance. • Primary 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 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 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 & Evaluation. Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention & control group.

9. Program Components: Client Flow Community Resources Self Chronic Care Model Management Collaborative Training Provider Patient Training Decision Support Nurse Case Management 15 - 20% of Patients Call Center Web-Based 80 - 85% of Patient Patients Registry Measurement & Evaluation: Randomized Controlled Trial & Overall Statewide Evaluation

10. ICDMP Status • Disease States: • Current: Diabetes, Congestive Heart Failure, Asthma • Future: Stroke/Hypertension, HIV/AIDS • Implementation: Phased In Statewide • Evidence Based Guidelines: Statewide Dissemination • Chronic Care Collaboratives: 3 Regional Collaboratives • Measurement & Evaluation • Monthly reporting – sample mandatory measures: • Design & implementation of randomized controlled trial

11. ICDMP Accomplishments To Date Percent of patients achieving: August ’03June ‘04 • HbA1c < 8 28.7% 59% • Self Management Goals 36.8% 57.2% • Blood Pressure <130/80 20.6% 28%

12. Challenges & Lessons Learned • Provider buy-in • Incentives: providers, recipients, partners/vendors • Integration with Managed Care Organizations (MCOs) • Data • Administrative vs. Clinical • Entry & Reporting • Cost savings / Return on Investment • Medicare Modernization Act – Part D

13. Critical Success Factors • NGA Policy Academy & Resources • Technical Assistance from National Experts (MacColl Institute, Institute for Healthcare Improvement, Center for Health Care Strategies, National Initiative for Children’s Healthcare Quality) • Chronic Care Model Foundation • Integration of Health & Medicaid • Legislative Support • CMS Support • Long Term View…..short term investment

14. ICDMP Resources • For More Information, such as • Provider Toolkit & Guidelines • Patient Self Management & Education • Training Materials • http://www.indianacdmprogram.com/