Medicaid program offers ‘coaches’ to nurse chronic ailments

Friday, November 2, 2007 | 3:00 p.m. CDT; updated 2:55 p.m. CDT, Tuesday, July 22, 2008

JEFFERSON CITY — Coaches are called upon to strategize and execute a game plan. In Missouri, there is a need for this type of coach — not to aid the floundering St. Louis Rams, but to help patients in lower income brackets who are suffering from chronic illnesses.

Nina Stewart is one of these coaches, and her work is part of the new direction Missouri is taking with its Medicaid program, renamed MO HealthNet.

Stewart tells one success story of a diabetic whose chances of achieving a healthy lifestyle have increased through the aid of a health care coach.

“A coach recommended to the patient the use of a food diary to help monitor blood-sugar levels; now the patient will have good news to deliver to the physician, instead of just bad news,” she said.

Stewart, a registered nurse with more than 30 years of experience, is one of the health care coaches recruited by the state to implement the Chronic Care Improvement Program, also known as CCIP. The program is aimed at improving the health of MO HealthNet participants who suffer from at least one of several chronic illnesses: diabetes, asthma, bronchitis and emphysema, acid reflux disease, heart disease and sickle cell anemia. The program began in November 2006.

“The reason we call it a chronic care program is because in the past, folks have just focused on a single disease, and not many of us are fortunate enough to have just one,” said George Oesterick, deputy director of MO HealthNet’s division of clinical services. “Often, if you have diabetes, you end up with lipid disease, or you end up with cardiovascular disease.”

Oesterick looks at the chronic care program as the possible backbone for the new MO HealthNet program.

Candidates get a “ticket in” because of a disease. They are contacted by a coach, informed of their eligibility to participate in the program at no additional cost, and can opt out if they do not wish to participate.

Stewart works in conjunction with a growing team of 13 health care coaches to field calls from participants and provide education and guidance. The coaches are supported by disease management and care coordinators as well as account managers. The call-up service is available 24 hours a day, seven days a week.

All the health care coaches working on the program are registered nurses, a qualification Stewart says is central to the role of the coach.

“They interact directly with the patient and reach out to them, take calls from them, help them coordinate their office visits, their referrals, determine if they need transportation to visits provided under Medicaid,” Oesterick said.

Stewart said the most tremendous benefit of a health care coach is that they are able to offer behavioral interaction that can empower patients to take charge of their health.

“Our role is to help them to find a piece of information concerning their health care,” Stewart said. “We are interested in how primary physicians can deal with health care challenges.”

About 140,000 of the state’s 825,000 Medicaid recipients are eligible for the Chronic Care Improvement Program. To date, about 53,000 patients have been enrolled.

The program is being rolled out section by section in the state. The Interstate 70 corridor and the northeast and southwest regions of the state have been reached, said Amy Woods, deputy director of pharmacy and clinical services in the for MO HealthNet Division.

The remaining eligible participants are scheduled to be enrolled by June 30, 2008, said Sara Anderson, spokeswoman for the Social Services Department.

The chronic care program is the state’s first electronic-based plan of care. A computer tool creates a ranking of high-risk, medium-risk and low-risk patients by compiling health care expenditures, diagnoses on health care claims and procedure codes from Medicaid recipients in the past year, Oesterick said.

The idea behind the electronic medical records approach is that it will enable providers, health care coaches and patients to collaborate, the concept being that health and state costs can both benefit from a more coordinated approach that focuses on a person’s overall lifestyle rather than specific medical symptoms.

“We know that around 80 percent of health care costs are dedicated to about 20 percent of patients; that is the concept behind CCIP,” said Karen Edison, co-director of the Center of Health Medicine at MU.

The state’s Social Services Department contracted with APS Healthcare, a private firm in Maryland that specializes in care management and behavioral services, to recruit the coaches and implement the health management system.

As of October 2007, the contract with APS has cost the state $6.75 million. That includes implementation costs and per-member per-month fees. The cost per member per month is $15.81.

The chronic care program is not mentioned specifically in the MO HealthNet legislation that replaced Medicaid earlier this year. However, the guidelines of the new program require that each recipient create a health improvement plan and have a health care home.

Ilalyn Irwin, a clinical instructor for health care policy at MU, said the idea of the Chronic Care Improvement Program is a step in the right direction, but that the population it is aimed at is a difficult one to manage.

“If you set up measures that don’t make sense to the patient, it won’t be successful. In the health care plan, a patient is told to eat more fruits, but if you go into a grocery store in a low-income neighborhood, you will know why this is hard; a patient is told to take a walk, but they live in an unsafe neighborhood. It’s a Catch-22,” Irwin said.

Woods said the challenges facing management of the Medicaid population was one impetus for the program.

“Historically, there have been some difficulties with making sure they get consistent care, to make sure they are doing what they need to do on a consistent basis,” Woods said.

The success of the program will be monitored electronically, measuring whether a patient has successfully followed requirements in the outlined plan of care.

“The better educated these people are about their disease and treatment, the more responsive they will be in keeping up with their meds and doctors visits, preventing the disease from worsening if at all possible,” Anderson said.

Since it began last year, the program has been moving along at a rapid pace, Stewart said.

In addition to educating participants, she said, it is important to continue to meet the growing need as the participant base grows.

“We are still conducting interviews for coaches on a daily basis for a reason,” Stewart said.

In Stewart’s experience as a coach, very few patients eligible for the program have opted out, creating a need to constantly acquire new resources. She said they are enrolling new patients in the program daily.

“Their enthusiasm is quite encouraging, because so many of them feel that they have pieces of information about how to improve their health care,” she said. “They are just happy to finally speak to someone on a one-to-one basis.”

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bahb whitlock November 6, 2007 | 9:51 a.m.

You misspelled the name - Dr. George Oestreich is correct

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