The Office of Vermont Health Access--Care Coordination Program.

The Office of Vermont Health Access (OVHA), administrator for Vermont Medicaid, has launched an innovative program to support high risk Medicaid beneficiaries in managing their chronic health conditions. The Care Coordination Program (CCP) provides short term, intensive case management services to the highest risk Medicaid beneficiaries who have one or more of 11 chronic health conditions. These conditions include: Arthritis, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Chronic Renal Failure (CRF), Congestive Heart Failure (CHF), Depression, Diabetes, Hyperlipidemia, Hypertension, Coronary Artery Disease (CAD), and Low Back Pain.

The OVHA's Care Coordination Program (CCP), in conjunction with the Chronic Care Management Program (CCMP), exemplifies the Chronic Care Model in action. The CCP and CCMP are the vanguard of a system redesign to improve the health outcomes of Medicaid beneficiaries. The Global Commitment to Health Waiver allows flexibility in the way Medicaid uses resources and is the first of its kind in the United States. The OVHA has committed to partnering with primary care providers, hospitals, Agency of Human Services (AHS) departments, community agencies and the Blueprint for Health Chronic Care Initiative in order to best address the need for enhanced coordination of services for individuals with chronic conditions in a climate of increasingly complex health care needs and scarce resources.

The goal of the CCP is to facilitate the beneficiary-provider relationship by offering services that assist providers in tending to the intricate medical and social needs of beneficiaries without increasing the administrative burden, and supporting the beneficiary to achieve self-management goals. Ultimately, the CCP aims to improve health outcomes, decrease inappropriate service utilization, and increase appropriate utilization of services among beneficiaries.

The Agency of Human Services' (AHS) reorganization recognized the need for coordination of services at the community level. As such, the Care Coordination teams are located primarily at the AHS local district offices to provide a unique and critical aspect of the AHS support network and to establish relationships with primary care providers that are focused on health outcomes. Care Coordination teams are embedded in their communities and well informed of local and statewide quality improvement initiatives and thus are able to assist providers and beneficiaries to access these services.

Method: Through a contract for population selection and monitoring services with the University of Massachusetts Center for Health Policy and Research (CHPR), claims data are stratified and run through a predictive modeling software tool in order to identify individuals at varying levels of risk for complications related to their chronic health condition(s). Individuals at the highest level of risk are contacted by the CCP nurse and medical social worker team to assess needs and develop a customized plan of care in collaboration with their primary care provider, using a holistic approach.

As supported by the Chronic Care Model (CCM), the CCP emphasizes evidence-based, planned, integrated and collaborative care for beneficiaries who exhibit high-prevalence chronic disease states, high-service utilization including pharmacy and/or frequent emergency department (ED) visits; and inpatient utilization. CCP staff working at the local level facilitate engagement of the Primary Care and other community service providers to support the beneficiary to achieve and sustain changes required for long term health outcome improvements.

Implementation: The CCP employs dyads of regionally-based Registered Nurse (RN) and Medical Social Worker teams working directly with beneficiaries, the primary care provider (PCP) and specialty care provider(s), AHS partners and community based organizations to devise the plan of care based on assessment of medical and psychosocial needs and gaps and/or barriers in implementation and achievement of the clinical treatment plan. Staff meet with participants in their home, the provider office and/or the community to facilitate the plan of care. Our professional teams also coordinate resources to support participants in developing self-efficacy skills and to help empower them to become active partners in their own health and well-being.

Consistent with the AHS' key practices, Care Coordination staff focus on customer service, holistic support and strength-based relationships in order to achieve effective health outcomes. It is well documented that chronic health conditions and their management are further complicated by the addition of mental health and/ or substance abuse disorders, and the basic challenges of food security, shortages of safe and affordable housing and limited public transportation to access required services. The OVHA CCP staff focus on the individual's hierarchy of needs and psycho-social indicators of health in addition to the chronic health condition to improve and sustain health. Teams have worked with as many as 20 different agencies and service providers over several months to achieve the priority health and security needs of participants.

Current Participating Providers, Agencies and Stakeholders: The CCP has engaged a broad spectrum of internal and external providers and stakeholders statewide in order to meet our mutual goals. Partners include: AHS partners in the Department of Health (VDH), Department of Children and Families (DCF), Department of Aging and Independent Living (DAIL) and the Blueprint for Health; hospitals, mental health service providers, primary care providers, substance abuse treatment providers, home health agencies, homeless shelters and others.

Provider Payments as part of CCP: A segment of the operating costs for administering the CCP are set aside for reimbursing participating providers. A strategy has been developed to provide an enhanced capitated reimbursement rate of $15 per month for CCP patient under management. To emphasize the importance of developing a joint plan of care with the primary care provider, the OVHA is reimbursing PCPs $55 for meeting with Care Coordination teams to develop the plan of care when one of their patients is enrolled in the intensive case management program. Similarly, providers are reimbursed $55 for the discharge meeting to emphasize the importance of a smooth transition to the CCMP once the initial plan of care with CCP has been achieved. The combination of incentive payments for meetings and the enhanced case management fee, which is $10 more than the PC Plus case management fee, provides primary care providers with an attractive incentive for participation in the CCP while also supporting mutual clinical goals for Medicaid patients under their care.

The OVHA's Chronic Care Management Program (CCMP): The CCMP portion of the OVHA initiative for beneficiaries with chronic conditions is administered under contract with APS healthcare. The CCMP is designed to address the needs of Medicaid beneficiaries with more moderate need on a continuum extending downward from the CCP population using telephonic assessment, coaching and mail support. Beneficiaries transition into the CCMP from the CCP when they are no longer in need of intensive case management services; however they need support to assist in sustaining changes initiated. Similarly, the CCMP may identify beneficiaries whose needs require more intensive service at the community level and these individuals are transferred into the CCP. The OVHA anticipates fluidity between the CCP and CCMP as beneficiaries move up and down the health needs continuum and transition between the CCP and CCMP.

When fully staffed, the CCP will employ 18 full time professionals' to administer the statewide initiative. While the CCP and CCMP initiatives are both young developmentally (under one year in provision of state wide services), we are slated to begin program monitoring for process improvements with chart extractions for baseline and early outcome data during the summer of 2008.

For more information on the OVHA Care Coordination Program please visit our web site at: http://www.ovha. vermont.gov/; or contact Eileen Girling at 879-5954.

Submitted by:

Eileen Girling RN, MPH, CAMS

Director, Care Coordination Program

Office of Vermont Health Access.