CHCS

CHCS

Center for Health Care Strategies, Inc.

Resource Paper

_________________________

Disability Care Coordination Organizations ? The Experience of Medicaid Managed Care Programs for People with Disabilities ______________________________

Susan E. Palsbo Center for Health & Disability Research National Rehabilitation Hospital* (now at the College of Health & Human Services, George Mason University)

Margaret F. Mastal Delmarva Foundation for Medical Care

_________________________

Funded by the Center for Health Care Strategies, Inc. under the Robert Wood Johnson Foundation's Medicaid Managed Care Program.

April 2006

281

Table of Contents

I. Executive Summary ___________________________________________ 3 Findings __________________________________________________ 3 Outcomes ________________________________________________ 5 Recommendations for States________________________________ 5

II. Introduction _________________________________________________ 6 Methods__________________________________________________ 6 Program Descriptions ______________________________________ 7 ACCESS II Care of Western NC, Asheville, North Carolina ___ 7 AXIS Healthcare, Minneapolis, Minnesota _________________ 9 Commonwealth Care Alliance, Inc., Boston, Massachusetts _ 12 Independence Care System, New York City, New York _____ 15 Vermont Medical Home Project, Montpelier & Burlington, Vermont ___________________________________ 18 Wisconsin Partnership Program (WPP) ___________________ 21 Community Health Partnership, Eau Claire, Wisconsin______ 21 Community Living Alliance, Madison, Wisconsin ___________ 24

III. Findings ____________________________________________________ 27 Participants; Characteristics ________________________________ 28 Benefits and Services _____________________________________ 28 Care Coordination Process ________________________________ 29 Organizational Structure___________________________________ 31 Staffing Configuration_____________________________________ 33 Titles _________________________________________________ 34 Team Models of Service Coordination____________________ 34 Advanced Practice Nurses ______________________________ 35 Mental Health Services _________________________________ 35 Information Management for Quality Improvement and Care Coordination Activities ____________________________________ 36 Quality Management and Outcomes ________________________ 37 Finances _________________________________________________ 38 Origins/Catalysts _________________________________________ 40 Governance______________________________________________ 42

IV. Outcomes and Recommendations _____________________________ 44 Finance and Utilization ____________________________________ 44 Quality of Life _________________________________________ 44 Satisfaction ___________________________________________ 45 Clinical Results ________________________________________ 46 Recommendations for States_______________________________ 46

Medicaid Managed Care Programs for People with Disabilities -- 1

Table of Acronyms

APN = advance nurse practitioner (a nurse licensed to provide some medical care and write prescriptions)

AXIS = AXIS Healthcare (located in Minneapolis. AXIS is not an acronym, but is always uppercase)

BSN =

bachelor of science in nursing (an RN with two more years of college training)

CCA = Commonwealth Care Alliance (private corporation in Massachusetts that contracts with Massachusetts

Medicaid)

DCCO = Disability Care Coordination Organization

CHG = Community Healthcare Group (group practice of physicians located at the Brightwood Health Center

in Springfield, Massachusetts)

CHP = Community Health Partners (holds a WPP contract for Medicaid elderly and disabled in Eau Claire,

Wisconsin)

CIL =

Centers for Independent Living (funded by the U.S. Department of Education to help people with

disabilities live independently)

CLA = Community Living Alliance (holds a WPP contract for Medicaid disabled in Madison, Wisconsin)

CMA = certified medical assistant

CMS = Centers for Medicare and Medicaid Services (federal agency that administers Medicare and Medicaid)

CPT = current procedural terminology (unique, 5 digit codes copyrighted by the American Medical

Association, assigned to every medical procedure)

CSHCN = children with special health care needs

DME = durable medical equipment

FTE =

full time equivalent

HMO = health maintenance organization

ICS =

Independence Care System (partially capitated managed care program in New York City)

ISP =

individual service plan (used by all DCCOs to operationalize person-centered care)

IT =

information technology

MCO = managed care organization

MDHS = Minnesota Department of Human Services (Minnesota's Medicaid agency)

MnDHO = Minnesota Disability Health Options (demonstration managed care program funded by Minnesota

Medicaid targeted to people with disabilities)

MIS =

management information system

OASIS = Outcome and Assessment Information Set data set that CMS uses in home health agencies to monitor

quality

OT =

occupational therapist

OVHA = Office of Vermont Health Access (Vermont's state Medicaid agency)

PACE = Program of All-Inclusive Care for the Elderly (a Medicare/Medicare program that allows frail elderly

needing skilled nursing services to receive those services in the community instead of a nursing home)

PCA = personal care assistant (provides non-medical services in a person's home)

PCCM = primary care case management

PCPM = primary care population management (North Carolina's approach)

PT =

physical therapist

PLA = personal living assistant (provides non-medical services in a person's home)

QI =

quality improvement

RN =

registered nurse (a two-year degree)

SCO = Senior Care Options (demonstration managed care program funded by Massachusetts Medicaid and

CMS, targeted to elderly)

SPMI = severe and persistent mental illness

WNC = Western North Carolina (generally, the mountainous part of the state)

WPP = Wisconsin Partnership Program (demonstration managed care program funded by Wisconsin Medicaid

targeted to elderly and people with disabilities)

Medicaid Managed Care Programs for People with Disabilities -- 2

I. Executive Summary

One of the greatest challenges facing every state Medicaid program is devising an appropriate and effective delivery system for its most resource-intensive beneficiaries. Children and adults with disabilities consume a disproportionately high quantity of Medicaid services, and their annual costs are increasing at the highest rate of all beneficiary groups.

One way for states to make their Medicaid expenses more predictable is capitation. Most states have turned to fully or partially capitated arrangements for Medicaid beneficiaries, and today, approximately 80 percent of beneficiaries are in capitated programs. Disabled beneficiaries are usually exempted from capitation and managed care because of fears of under-treatment, restricted access to services and providers, and poor quality.

Bucking this trend are several pilot programs. Most of them have strong roots in working with people with disabilities. The programs are taking the best attributes of managed care and reconfiguring them to improve the lives of Medicaid beneficiaries with disabilities. We visited seven pilot programs during 2004. This paper synthesizes the programs' key components and describes the challenges they face in documenting their effectiveness to advocates and regulatory agencies. A companion paper presents a strategy to report comparative measures of program outcomes.

Findings

Following are our key findings:

Findings on Mission

? The primary mission of each program is to coordinate publicly funded medical and social services. They blend attributes of social services agencies and health care agencies. We refer to these new entities as: Disability Care Coordination Organizations (DCCOs).

Findings on Scope of Coordinated Services

? Medicaid beneficiaries in DCCOs have most or all of their benefits coordinated by the DCCO.

? DCCOs targeting people with physical disabilities coordinate DME, transportation, and personal care assistance; they may also provide non-Medicaid supplements to these services (e.g., in-home wheelchair repair).

? Capitated DCCOs offer supplemental benefits, funded out of cost savings. ? PCCM and fee-for-service models are unable to offer supplemental benefits.

Findings on Care Coordination Process and Key Functions

? Engage participants in writing a self-directed, patient-centered plan of care. ? Collaborate with other agencies, providers, and vendors to meet participants' needs. ? Organize and disseminate information across all agencies and providers.

Medicaid Managed Care Programs for People with Disabilities -- 3

? Communicate proactively with each participant on a regular basis, timed to meet participants' needs.

? Attend clinical visits when needed. ? Available to participants 24/7.

Findings on Organizational Structure

? Organizational structures range from being a specialty service provider to a full-fledged HMO.

? The DCCO is a flexible, robust approach to support independent living in the community, and person-centered and consumer-directed care, across a variety of disabling conditions.

? Care coordination models reflect the community environment and populace they serve. ? Three "core competencies" are: service coordination, patient education, and quality

improvement.

Findings on Staffing Configuration

? Caseloads range from 20-75 participants per care coordinator. ? Some DCCOs stratify their participants by resource need to distribute the coordination

burden equitably across the coordinator structure. ? Most DCCOs invest significant time and resources to develop productive teams and

interdisciplinary cognizance between nurses and social workers. ? DCCOs using combined nurse-social worker teams house the teams at the corporate

office, providing dedicated physical space for each team. ? DCCOs embedding nurse coordinators in physician offices link them with the expertise

of social workers. ? DCCOs in states with advanced practice nurses are evolving models that best utilize their

education and training in the comprehensive care coordination process. ? DCCOs targeting persons with physical disabilities must address mental health issues and

develop expertise among care coordinators for dealing with these concerns.

Findings on Information Systems

? DCCOs are internally developing separate and distinct information management systems for the care coordination of their complex populations.

? Extensive relational databases are needed for effective care coordination of complex populations.

Findings on Quality Management

? There are few shared measures across DCCOs, partly because they target different types of disability clusters.

? The sophistication of quality measurement and reporting (number of measures, process to select measures, input of data to create measures) varies widely across sites.

Medicaid Managed Care Programs for People with Disabilities -- 4

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