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MODULE 12  : Designing and Developing Disease and Care Improvement Programs

This module discusses how Community Care designed, developed and implemented its approach to population management, including a number of our disease and care management initiatives. Linkages to tools and educational materials already developed to support the implementation of the initiatives are included.

Overview

Like most states, North Carolina continues to face the perpetual challenge of providing high-quality and cost-efficient care to its Medicaid population. Under the Community Care program, the state has built a robust community-based system that is organized and operated by local physicians, hospitals, health departments and departments of social services. By establishing these private, not-for-profit provider networks, the program has put in place the local systems and resources such as disease management programs needed to effectively manage a patient population. Other population management components include, but are not limited to; care management; prevention; treatment of acute and chronic conditions; pharmacy management; specialty referrals and self-management.

Community Care is designed to support the development of community-based systems that can develop programs and processes to manage the care of an enrolled population. As cited in other modules, the local systems include:

  • Linking enrollees with primary care providers to create medical homes.
  • Clinical and administrative leadership who provide direction on care and disease management interventions and activities.
  • Dedicated care managers who can carry out population management activities in care and disease management.
  • Using existing community resources in the program design, such as health department services and aging coalition support services, to meet enrollees’ needs.

As was described in “Designing and Developing Care Improvement Strategies”, the Community Care’s Clinical Directors have established the following principles to guide the selection of care and disease management initiatives:

Current Program-Wide Disease and Care Management Initiatives

Community Care has the following disease and care management initiatives in place in every network:

  • Asthma disease management.
  • Diabetes disease management.
  • Congestive heart failure disease management.
  • High-cost and high-risk care management.
  • Pharmacy management and prescribing initiatives.
  • Emergency room utilization.

In addition, Community Care has a chronic care initiative (see Module 13) in place in every network and began in the summer of 2010 to implement a statewide mental health integration effort. As of this writing, pilots were underway in several networks creating models of care relevant to Community Care’s target population. Examples include, but are not limited to:

  • Chronic Obstructive Pulmonary Disease (COPD) management.
  • Stroke prevention.
  • Childhood obesity.
  • Mental health integration/co-location initiative.

Community Care provides centralized support to the networks by providing the following support activities and resources:

  • Clinical expertise and leadership to meet with physicians and practices on targeted care and disease management initiatives.
  • Clinical staff that are available to meet onsite with practices and their staffs and provide disease management “101” on targeted diseases.
  • Provider toolkits that summarize best practice guidelines and provide office-based tools for adoption and/or customization.
  • Quarterly practice profiles on utilization, cost and quality indicators are created and disseminated to all participating practices/providers.
  • A web-based case management information system (CMIS, described in the Informatics Module) supports the case manager’s efforts and contains useful tools, such as uniform screenings and assessments for targeted disease initiatives (e.g., quality of life assessment for enrollees with COPD).
  • Provider and patient education materials that can be printed and customized for individual practices (e.g., medical home brochure with space to print the practice name and contact information).

Community Care uses the performance measures defined by the Clinical Directors to measure the ability of providers and networks to establish quality processes and to achieve quality outcomes for the core program initiatives. The outcome indicators are typically gathered from claims data and the process indicators from external chart reviews. Community Care has contracted and partnered with Area Health Education Centers (AHECs) to perform randomized chart audits that provide practice specific feedback and monitoring on process measures, such as performing annual foot and eye exams on patients with diabetes. In this process, a standard chart audit tool is developed and a randomized representative sample of charts is identified for review. Please refer to Module 10 for more detailed information about our clinical improvement processes.

The remainder of this module provides summary information on our core disease management initiatives along with links to tools and guidelines used in the program to support the care managers and primary care providers.

Asthma Disease Management Program

The Asthma Disease Management Program was the first program-wide quality improvement initiative developed by the Community Care Clinical Directors in 1998. The decision to address asthma was based on established guidelines for selecting a quality improvement (QI) initiative and on a review of Medicaid claims utilization data. The source for much of the utilization data was a 1999 report from the N.C. State Center for Health Statistics titled The Childhood Asthma in North Carolina Report.

  • In fiscal year 1998, the North Carolina Medicaid program spent more than $23 million on asthma-related care.
  • Approximately 14 percent of the Medicaid population had been diagnosed with asthma.
  • Analysis of Medicaid claims data for Community Care enrollees demonstrated that the primary reason for both hospital and emergency room visits for patients under 21 was asthma.

Core Elements of the Asthma Disease Management Program

The Community Care Clinical Directors adopted core elements for the Asthma Disease Management Program. These core elements identified best practices and formed the basis of the initiative implemented by the networks and participating providers and practices. Listed below are the core elements of the Asthma Disease Management Program:

  •  Build capacity for routine assessment of asthma.
    • Adopt National Institutes of Health guidelines for the diagnosis and management of asthma.
    • Develop and implement a method for identifying and recruiting asthma patients in the participating networks.
    • Develop and implement a simple questionnaire that allows providers to quickly stage the severity of a patient with asthma.
    • Develop a method to record symptom frequency on a regular basis.
    • Establish peak flow meter readings as a tool for all patients with asthma, and record the peak flow at all appropriate times and in all appropriate settings.
    • Record each patient’s personal best peak flow in the medical record and/or care management plan.
    • Use spacers/holding chambers when appropriate.
    • Identify one staff person in each practice as the “asthma QI champion.”
  • Reduce unintended variation in care, and establish consistency of care.
    • Educate all medical personnel regarding the proper use of maintenance medications based on the National Institutes of Health (NIH) guidelines.
    • Educate all medical personnel regarding the stepwise approach to asthma management based on NIH guidelines.
    • Offer practice profiling as a part of this effort; i.e., conduct detailed visits with physicians and their staff members to review each practice’s prescribing histories, including a case-by-case discussion of diagnoses and recommended medications.
    • Use case managers to coordinate information gathering, transfer and care delivery, as appropriate.
    • Assess home environments for smoking, allergenic materials and other known asthma triggers.
    • Coordinate sharing of information among all caregivers.
  • Build capacity to educate patients, families and school personnel about asthma.
    • Develop and implement asthma action plans that include the patient monitoring peak flow meter readings when appropriate.
    • Develop the capacity to teach patients with asthma and caregivers how to properly use peak flow meters, inhalers, spacers and/or holding chambers.
    • Collaborate when possible with school nurses, teachers, administrators and day care center personnel to assure appropriate education, assessment and treatment for school-age children with asthma.
    • Educate family on symptom-based management for children who cannot use peak flow meters.
  • Report outcomes and process measures to all providers and staff regularly.
    • Develop the information system capability to collect, monitor and analyze data for measuring performance.
    • Collect and disseminate information by physician, by practice and by network.
    • Use this information to assess current performance, encourage efforts to improve care processes at all levels, and set goals for performance improvement targets.

Performance Measures for Asthma

Community Care has adopted performance measure to monitor progress of enrollees in different disease categories. For asthma, the following measures are among the key indicators used.

Outcome measures (obtained from Medicaid Claims):

  • Emergency department utilization rate.
  • Emergency department utilization rate for asthma.
  • Inpatient admission rate.
  • Inpatient admission rate for asthma.

Process measures (obtained from annual chart audits):

  • Percentage of patients with asthma staged.
  • Percentage of patients with asthma staged II, III, or IV on maintenance medications.
  • Percentage of patients with asthma staged II, III or IV with a written asthma management plan.
  • Percentage of patients with asthma receiving an annual influenza vaccine.

Practice and Provider Supports

Community Care network and central office staff members supply participating practices and providers with a variety of supports and tools for implementing the Asthma Disease Management Program. Highlights include:

  • Provider toolkits with best practice guidelines (adapted from the National Asthma Education and Prevention Program’s Guidelines on the Diagnosis and Management of Asthma. National Institutes of Health National Heart Lung and Blood Institute).
  • Technical assistance in quality improvement and provider educational sessions.
  • Program, network, practice and patient data on process measures (chart audits), outcomes measures (emergency room and hospital utilization data) and other data extracted from the Medicaid claims system.
  • Office tools such Asthma Action Plans and Patient Questionnaire samples to determine severity of disease and Asthma Visit Forms to prompt providers on recommended clinical management and patient education.
  • Case management services for patients with asthma:
    • Disease specific assessment.
    • Medication adherence counseling.
    • Coordination of care.
    • Follow-up form for emergency department and inpatient visits.
    • Education on community resources.
    • Education on disease, medication, equipment and avoidance of triggers.
    • Practice assistance with quality improvement and the “plan, do, study, act” (PDSA) cycle.
  • Dedicated pediatrician or family physician leading the asthma initiative who is available to provide the following types of activities and technical assistance:
    • Asthma training and educational sessions to physicians, practice staff and/or case manager.
    • Update and present findings to network clinical directors.
    • Serve on local and state level asthma advisory groups and committees representing Community Care.
    • Update and present findings at local network level to staff and physicians.
    • Research and make recommendation for program changes and enhancements.

Summary of Results:

  • Between FY 2003 and FY 2006, Community Care saw a 16.6 percent decline in the rate of admissions to emergency departments among the patient population.
  • During the same period of time, there was a 40 percent decrease in the admission rate for patients with a diagnosis of asthma to inpatient facilities.
  • Practices that had been enrolled in Community Care for more than one year did better in the four key performance measures than newly enrolled practices in the program.

The following attachments to this module are relevant to Community Care’s Asthma initiative:

Diabetes Disease Management Program

The Clinical Directors chose diabetes as the second program-wide quality improvement (QI) initiative in 2000. Following the guidelines for selecting a QI initiative, the decision was based on the following factors:

  • There was a high percentage of adults with a diagnosis of diabetes with inpatient admissions and emergency department visits.
  • Diabetes is a predominant disease among the adult Medicaid population, and the incidence is increasing.
  • Poorly managed or uncontrolled diabetes may lead to multiple serious and costly long-term complications.
  • Evidence-based best practice guidelines for the care of diabetes are evidence-based and accepted in the medical community.
  • There was room for improvement in the management and care of enrollees with diabetes.

Core Elements of the Diabetes Disease Management Program

The planning and development of the Diabetes Disease Management Program occurred in 2000, and we began implementation in January 2001.
The Diabetes Quality Improvement Initiative is built on the core components of process improvement and patient outcome improvement. Based on national studies, improving the quality of care people with diabetes receive can result in a variety of benefits to the individual and cost savings to the health care system. Several long-term studies, most notably the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), have shown that improved glucose control, improved blood pressure control and improved lipid control can delay the onset and progression of diabetes complications. Improving metabolic control, blood pressure control and preventing complications requires primary care, follow-up care and education that is consistent with evidence-based practice guidelines. Community Care is committed to improving the quality of care provided to our patients with diabetes. This initiative has been designed based on guidelines developed by the American Diabetes Association (ADA) and national models for improvement.

Diabetes Program Summary

The following steps are defined as the core elements of the Diabetes Initiative:

  • Criteria for Diagnosis and Standards for Best Practice
    • Clinical Directors adopt ADA (American Diabetes Association) criteria for diagnosing diabetes and ADA Clinical Practice Recommendations to define Best Practice guidelines and audit measures.
  • Identify and Implement Diabetes Teams
    • Networks identify and recruit Diabetes Champions and multidisciplinary staff resources within their local practices and communities.
    • Diabetes Teams work with providers and practice staff to achieve QI goals based on data from program-wide audits.
  • Define and Develop Diabetes Resources and Tools
    • Develop and customize tools, tailored to meet the varying needs of each Network.
    • Define the practice assessment process to determine the patient’s needs and assets.
    • Develop a diabetes education program to maximize diabetes self-care behavior.
  • Enhance Partnerships with Community Resources
    • Identify, collaborate, and coordinate with existing community resources.
    • Develop and implement processes of communication with hospitals to follow-up with patients who have diabetes.
  • Develop Materials and Tools for Provider Education and Buy-In
    • Customize tools; identify and meet new needs on an ongoing basis.
    • Provide technical assistance to practices for implementation of PDSA (plan, do, study, act) cycles targeted to improve provider processes and patient outcomes.
    • Work with practice level “Diabetes Champions” to track and monitor program implementation.

Diabetes Disease Management Program Performance Measures

The Community Care network leadership chose the following outcome measures:

  • Inpatient Admission Rate
  • Inpatient Admission Rate for Diabetes
  • Emergency Department Utilization Rate
  • Emergency Department Utilization Rate for Diabetes

The following process measures were chosen for adults and children, as indicated by the American Diabetes Association’s (ADA) guidelines:

  • Diabetic flow sheet in use on the medical record.
  • Continued care visits at least twice yearly.
  • Blood pressure at every continuing care visit.
  • Referral for dilated eye/retinal exam every year.
  • Foot exam every year.
  • Monofilament/sensory exam every year.
  • Glycosylated Hemoglobin (HgbA1c) at least twice in 12 months.
  • Annual lipid profile.
  • Annual flu vaccine.
  • Pneumococcal vaccine done once (repeat if the first dose was given at age 65 or younger and the patient is now older than 65, and the first dose was given more than five years ago).

Practice and Provider Supports for Diabetes

Community Care networks and central office staff provide participating practices and providers with a wide range of tools and supports for implementing the diabetes disease management initiative, including, but not limited to, the following:

  • Provider toolkit with best practice guidelines and office tools, such as diabetes flow sheet.
  • Program, network and practice level data on process and outcome measures.
  • Technical assistance in quality improvement, diabetes care and targeted educational sessions for providers and care managers.
  • Targeted care management support and interventions.
  • Dedicated diabetes nurse educator to lead the initiative and provide training, technical assistance and follow-up.

Summary of Results

  • Ninety-four percent of Community Care enrollees with diabetes see their PCP at least two times a year to address their diabetes.
  • Ninety-six percent of Community Care enrollees with diabetes have their blood pressure measured at each PCP visit.
  • Approximately 70 percent of enrollees with diabetes have annual lipid tests, foot exams and HbA1C tests performed every six months.
  • Average A1C level for Community Care enrollees with diabetes is 7.7 percent.

The following attachments to this module are relevant to Community Care’s Diabetes Program:

Pharmacy Management Initiatives

Due to the importance of medication management, we have included a dedicated module to provide more detailed information about Community Care’s pharmacy initiative, including our more recent Pharmacy Home Program. We began our efforts in pharmacy when the Clinical Directors chose pharmacy as a quality improvement and cost containment effort in the fall of 2002. Their decision was influenced by the following utilization data:

  • Pharmacy costs had seen the greatest increase in expenditures for Medicaid overall and for the Community Care networks.
  • Pharmacy expenditures had increased approximately 37 percent in one year.
  • There were a high number of Medicaid enrollees on eight or more prescriptions each month (Note: Polypharmacy – taking an unusually high number of prescription medications – can be problematic as there is a greater chance of drug interactions and adverse effects the more drugs a person takes).
  • The initiative provided an opportunity to improve quality and reduce costs.

The pharmacy initiative consisted of the following components:

Prescription Advantage List (PAL)

This tiered medication list was developed by the Community Care Clinical Directors and the N.C. Physicians Advisory Group (NCPAG) in cooperation with the N.C. Division of Medical Assistance as an effort to control rising drug costs. The physician leadership of the NCPAG and Community Care hoped that the information guide would help change physicians’ prescribing behaviors for selected commonly prescribed high-cost, high-utilization drugs when less expensive alternatives or generics were available and clinically appropriate.

The PAL included some of the most costly medication classes incurred by North Carolina’s Medicaid program. By evaluating the net cost per unit of each medication (including rebates), the medications in each class were ranked in order from least to most expensive and placed in one of three price tiers. The tiers were calculated on a quartile distribution system utilizing all medications’ net cost per unit in the drug class. The lowest-cost drugs were assigned to Tier 1, and the most expensive medications were included in Tier 3. No judgment as to the efficacy was implied by the list; rather, the PAL was intended strictly as an informational guide that solely provides information on costs. 

Community Care also printed and distributed PAL pocket cards listing selected medications that were identified using a more stringent process. To be listed on the pocket card, the drug had to meet the following criteria:

  • The drug was identified as a commonly prescribed drug (or drug class) by Medicaid providers in North Carolina (i.e., it was listed in the North Carolina Medicaid program’s top 200 drug utilization list).
  • The drugs were in a class with a significant price differential between drugs ( more than a 25 percent cost differential) based on cost analysis from the most recent quarter available and a review of six to nine months of prior data to discern trends of cost per drug and drug dose.
  • After a review of DERP (Drug Effectiveness Review Project) findings and/or other research data, evidence existed to compare efficacy and safety among the drugs in the class as well as trials with head-to-head comparisons of drugs within the class when available.

In June 2007, Medicaid began a prior authorization program for proton pump inhibitors (PPIs), and in 2008, North Carolina’s Medicaid program began a prior authorization program for second-generation antihistamines.

(Note: For current prescribing information, you can visit the U.S. National Library of Medicine  for the most recent FDA-approved prescription guidelines. You can also review the Drug Effectiveness Review Project (DERP) housed at Oregon Health and Science University. The DERP comprises a wide range of organizations across the country that research and provide evidence-based data on medication effectiveness and safety within each drug class.)

Polypharmacy in Nursing Homes

In the spring of 2002, Community Care conducted a pilot program in 11 nursing homes throughout the network. Community Care physicians and clinical directors partnered with a pharmacist and the nursing homes’ administrative and medical leaders to review all Medicaid residents’ drug regimens. This initiative focused on better management of prescribing practices for a patient population that averages nine prescriptions per month and resides in a nursing facility. The team developed reports to track findings and results as well as a guide to the initiative to provide consistency and structure for the review. In this pilot, pharmacists and physicians reviewed patients taking drugs that met some or all of the following criteria:

  • Were therapeutic duplications.
  • Appeared on the PAL.
  • Appeared to have an excessive length of therapy.
  • Were on a list developed by a committee of long-term care pharmacists that featured drugs associated with potential significant savings.
  • Were medically questionable based on published review lists (e.g., the Beers List identifies drugs considered inappropriate for the elderly because they often cause adverse reactions).

The results from this review demonstrated an opportunity to reduce costs and increase the quality of care. The initiative went statewide in November 2002. AccessCare, Inc., Community Care’s largest network, has published several papers outlining the project and results. Drug cost savings averaged $30.33 per patient per month with 74 percent of patients receiving a change recommendation. As a result of this Community Care pilot, North Carolina implemented a similar project with nursing homes throughout the state.

Polypharmacy in Ambulatory Care

This component of the pharmacy initiative began in October 2002. The Ambulatory Polypharmacy Project represents an effort by the Community Care Clinical Directors to reduce drug interactions and adverse effects and eliminate unnecessary drug costs. The target population for this project included patients age 50 or older who had more than 24 prescription claims in a three-month time period. We arranged to have a local consultant pharmacist available for each Community Care network to help physicians review patients who took more than eight medications per month. Criteria similar to the Nursing Home poly-pharmacy initiative were used.  To qualify, the drugs:

  • Were therapeutic duplications.
  • Appeared on the PAL.
  • Represented brand names when generic substitutions were available and appropriate.
  • Were medically questionable based on published review lists (e.g., the Beers List identifies drugs considered inappropriate for the elderly because they often cause adverse reactions).

Practice and Provider Supports for Pharmacy

Working closely with the North Carolina Division of Medical Assistance (DMA), Community Care continues to implement new pharmacy initiatives (see Pharmacy module) to help improve patient outcomes and control costs. We found that the most critical part of all of our pharmacy programs is the addition of a Doctor of Pharmacology (PharmD) to the local networks. Based upon patient enrollment, each network receives funds to hire a part-time or full-time PharmD to assist with the education, coordination, roll-out and oversight of all pharmacy benefit programs within the network.

Beginning in 2007, Community Care began to manage patients on six to 11 medications and helped support DMA’s Focused Risk Management Program (FORM) targeting patients who take more than 11 prescriptions. Education and relationship building are important aspects in successfully managing patients on multiple medications. The role of the PharmD has proven instrumental in establishing valuable relationships with the retail pharmacists, community physicians and patients to improve communication and help resolve medication-related issues. Further, the PharmD can educate providers and patients to help ensure appropriate and cost-effective medication use.

The PharmD position also supports networks as they expand pharmacy management programs to other patient populations, such as the Aged, Blind and Disabled. In 2005, the North Carolina General Assembly directed Community Care to improve the management, cost-effectiveness and coordination of local services for this population that represents nearly 70 percent of the state’s Medicaid budget. Creating a “pharmacy home” as well as a medical home for these patients will help contain costs and ensure that appropriate medications are prescribed according to the care plan. Using targeted interventions, the PharmD and case managers work in concert to increase medication adherence, increase the use of Tier 1 or OTC prescriptions where clinically appropriate, and decrease the number of patients on regimens with known drug interactions. In addition, the pharmacist is an integral part of the interdisciplinary team that works with individuals with chronic disease to improve self-management skills.

Summary

As the prescription drug share of the Medicaid budget continues to increase, Community Care continues to identify opportunities to better manage the pharmacy costs of its enrollees. Community Care has found that helping physicians identify cost-saving drugs through the PAL, managing populations on multiple medications more effectively and creating partnerships that improve the coordination of care are successful methods to enhance therapeutic outcomes and improve the quality of health while providing cost-effective care.

The following attachments and resources to this module are relevant to Community Care’s Pharmacy Program:

Emergency Department (ED) Utilization Initiatives

The purpose of the Community Care emergency department (ED) initiative is to decrease non-urgent use of the ED by providing a standardized approach to help network manage the appropriateness of ED visits. Several reasons precipitated this effort:

  • The Balanced Budget Act in 1997 and the interpretation of the EMTALA (Emergency Medical Treatment and Active Labor Act) regulations emphasized the prudent layperson's definition of an emergency.
  • The Medicaid agency removing the Carolina Access emergency room policy because the Center for Medicare and Medicaid Services (CMS) believed it violated the Balance Budget Act and EMTALA guidelines.
  • There was a tremendous increase in ED use across the state and the Community Care networks, averaging approximately a 30 percent increase in one year.
  • Community Care recognized there was a great opportunity for cost savings if non-urgent care could be redirected to the primary care provider's office.

Begun in August of 2002, the project focused on outreach, follow-up and education. The initial ED utilization project targeted Community Care enrollees who had used the ED more than three times in the previous six months. These individuals were identified by quarterly reports that served as a tool for care managers to use in their educational outreach efforts. In addition, networks were encouraged to develop relationships with their local hospitals and obtain real-time data enabling more immediate and meaningful follow-up with enrollees. Over the years, most of our networks were able to get “real-time” information from the hospitals on the enrolled population’s use of the ED. Some networks, in fact, have embedded care managers to provide on-site follow-up and education and participate in discharge planning. Most recently, the Community Care Informatics Center is in the process of obtaining admission, discharge and transfer data from a vendor for the hospitals who supplies the data to the state.

In 2003, the Community Care networks began working with Health Check Coordinators (HCC) in selected counties to assist in the follow-up and education of enrollees who had visited the ED. This collaborative effort proved to be a natural fit since HCCs focus all of their time on families, working to assure that children receive routine well-child check-ups. The collaboration was expanded across the state in 2004 when ED follow-up was added to their duties. 

In collaboration with the Division of Public Health and the N.C. Healthy Start Foundation, Community Care developed an educational campaign aimed at increasing awareness of the medical home concept and decreasing inappropriate ED visits. Designed as patient education tools, the medical home materials (bookmarks) highlight the three most common reasons for pediatric ED visits: ear infections, fever and colds/upper respiratory infections (including the flu). In addition, this campaign promotes the value of preventive services and having a consistent source of primary care services. (Note: digital artwork for bookmarks is available here and can be downloaded and customized for specific practices or networks.) 

Congestive Heart Failure Management Program

The Congestive Heart Failure Program was the third statewide disease management program developed by Community Care. Building on the success of the asthma and diabetes programs, North Carolina legislators in 2004 urged Community Care to develop a new core disease management program. After reviewing prevalence and outcome date for several chronic diseases, the Clinical Directors chose to design a program to improve the quality of care and health outcomes for enrollees with congestive heart failure. Several heart failure disease management models existed that had clearly demonstrated improved outcomes, including decreased mortality, hospitalizations, enhanced quality of life and decreased cost. The development of the Heart Failure Program started in 2006, and all 14 networks began to implement the program the following year.

National Burden of Illness

Heart failure has a tremendous impact on individuals’ functional status and quality of life. Patients are frequently hospitalized and suffer from chronic shortness of breath and fatigue. Nationally, heart failure is the most common cause of hospitalization for the elderly and accounts for 5.4 percent of healthcare expenditures or $38 billion. Ten percent of congestive heart failure patients are re-hospitalized within six months.

North Carolina Data

In North Carolina, heart failure is the second leading cause of preventable hospitalizations, more than half of which is thought to be avoidable (note: lack of adherence to medications and diet accounts for 41 percent of hospitalizations due to heart failure). Further, expenditures for enrollees suffering from heart failure far exceed those for individuals with diabetes or asthma. In the Community Care program, about 3,000 individuals are identified with heart failure, while there are more than 17,000 enrollees with either diabetes or asthma. The annual mean Medicaid expenditures for each group tell a startling story, though; the figure for enrollees with heart failure is $27,000, while it is $7,900 and $12,000 for people with asthma and diabetes, respectively.

  • Fortunately there are opportunities to improve outcomes for people with heart failure by promoting evidence-based therapies, improved self-management and access to a medical home.
  • Modifiable factors leading to hospital readmissions for heart failure include, but are not limited to:
  • Inadequate patient and caregiver education and counseling
  • Poor communication among healthcare providers
  • Failure to organize follow-up care
  • Clinician failure to emphasize non-pharmacologic aspects of heart failure care (e.g., diet, activity and symptom monitoring)

Best Practices for Managing Heart Failure

The optimal disease management approach focuses on case management of high-risk individuals to promote adherence and self-management, and working with clinicians to follow evidence-based clinical practice guidelines. A decline in health status can often be prevented if patients or caregivers are able to monitor symptoms and daily weights. Rapid increase in weight often is a sign of worsening heart failure. If these patients are able to access healthcare promptly where their medication can be adjusted, costly hospitalizations often can be avoided.

Medication adherence is also a key issue in keeping these patients healthy. Angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) and beta blockers have been shown to reduce mortality, prevent hospitalization and improve quality of life for individuals with heart failure. Patients are often on complex medical regimens, and frequent monitoring and support are necessary to help patients benefit from the therapies. Case managers contact high-risk individuals frequently and refer them to care when needed.

Heart Failure Program Design Summary

Identifying the Heart Failure Population:
The program primarily uses claims data to identify individuals with heart failure. Individuals are also identified at hospital discharge and by referrals from physicians.

Improving Quality of Care in Community Care Practices:
The network Clinical Directors reviewed several heart failure clinical practice guidelines and decided to adopt the ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult statewide. Working with clinical experts in heart failure, Community Care developed a Heart Failure Toolkit to promote best practices in heart failure management. Each network identified a primary care physician champion and a cardiology physician champion. The Network Clinical Director and Network Coordinator, along with the Medical Management Committee and physician champions, work with practices to improve quality of care for heart failure patients. The Network also identifies community resources such as hospital-based heart failure programs and case management programs.

Measuring Improvement:
The network Clinical Directors reviewed the literature for evidence-based measures that are effective in changing practice and improving outcomes. These measures evaluate whether an accurate diagnosis is made, whether patients are prescribed evidence-based therapies, medication adherence, utilization, cost and whether case managers assess individuals regularly. Heart failure performance reports are distributed to networks on quarterly intervals with performance data at the individual network and state levels.

Community Care Heart Failure Case Management Program:
Effective case management models for heart failure involve identifying and contacting a high-risk population regularly.

  • All heart failure patients have a comprehensive assessment every 12 months.
  • Those who are determined to be high risk are contacted weekly for approximately six months.
  • Those developing symptoms of a heart failure exacerbation are referred to their primary providers.

During phone calls or visits, case managers provide self-management support, educate individuals and caregivers about the disease process, promote medication adherence and help identify early signs of a heart failure exacerbation. A patient-centered tool kit was developed, “Managing Your Heart Failure,” to promote self-management. Individuals are assessed with a Web-based assessment tool that is integrated into the Case Management Information System (CMIS). The tool determines the clinical status of the patient, educational needs, medication adherence and psychosocial needs. The CMIS Heart Failure Module allows case managers to assess individuals over the phone and then transmit messages and tasks to local case managers who can address individual needs. Measures are collected in the module that will be used in evaluating the effectiveness of the program.

Heart Failure Program Performance Measures

The Community Care network leadership chose the following outcome measures:  

  • Heart Failure Hospitalization Rate
  • Heart Failure Readmission Rate
  • Heart Failure Emergency Department Utilization Rate
  • Mean Heart Failure Enrollee Cost

The following process measures were chosen:

  • Percent Heart Failure Patients with Echocardiogram in past three years
  • Percent with Ejection Fraction lower than 40 percent, prescribed ACE Inhibitor or ARB after identification with heart failure
  • Percent with Ejection Fraction lower than 40 percent, prescribed Beta Blocker after identification with heart failure
  • Percent of those prescribed ACEI or ARB, filling prescription at least 80 percent of months in claims database
  • Percent of those prescribed Beta Blocker, filling prescription at least 80 percent of months in claims database

Practice and Provider Supports

A successful heart failure program will have a substantial impact on improving both the quality of life and health outcomes for Medicaid recipients with heart failure. There is also opportunity to garner savings by decreasing hospitalization rates and improving the efficiency of utilization in this population.

The Community Care Heart Failure Program capitalized on the relationships that have been fostered between network case managers and physicians and the collaborative learning process that occurs between networks. The majority of heart failure disease management programs designed by payers are “carve out” programs where case managers work remotely from patients and do not have established relationships with physicians, hospitals, or public health. Community Care found the local relationships and networking an essential component of the model.

There are several challenges that were identified in working with the Medicaid Heart Failure population. In evaluating baseline performance data, it seems that North Carolina health care providers caring for this population are prescribing evidence-based therapies at high rates compared to national benchmarks. Among people prescribed these medicines, however, only half take their medications regularly. These data reinforce the need for case managers to support self-management and medication adherence. The program also relies heavily on contacting patients frequently by phone.  Medicaid recipients often are difficult to contact and may move frequently. Networks use their established relationships with practices, social services, and hospitals to engage these individuals. Heart failure patients can remain healthy if they learn to self manage their disease and work closely with healthcare providers to adhere to optimal therapies. Community Care’s networks are well designed to improve the health outcomes and quality of life for North Carolina Medicaid’s heart failure population through improving quality of care in Community Care practices and through case management of individuals with heart failure.

The following attachments and resources are relevant to Community Care’s Heart Failure Program:

Pilot Initiatives

In addition to the core program initiatives described above, many individual networks developed and implemented their own pilot efforts. Their interest to implement pilots may be due to the following:

Assuring Better Child Development (ABCD)

One example of a pilot effort that began in one network but then spread to all fourteen is the ABCD (Assuring Better Child Development) program.  In early 2000, this initiative began with grant support from the Commonwealth Fund and the commitment and leadership from one network Clinical Director, a developmental and behavioral pediatrician who became the champion for this initiative at the state and national level.

The program began with a two-step approach:

  • Step I – Development of a comprehensive community model.
  • Step II – Formation of a state advisory group comprised of key agency leaders with the authority and ability to make necessary policy changes.

The key objectives included but were not limited to:

  • Develop and implement a model program for Medicaid children that encompasses their health, social and developmental needs.
  • Secure local community involvement.
  • Integrate services to help ensure the most efficient use of current resources by maximizing the use of  existing services and minimizing duplication.
  • Identify and respond to parental developmental concerns.
  • Monitor and track the impact on Medicaid policy.

As a child’s primary care physician is likely to be the most-informed professional with whom the family has regular contact during the child’s first five years, he or she can be invaluable in helping to spot children with developmental delays. The "ABCD" model was designed to identify and develop a set of best practices that primary care physicians can use to identify and refer children, from birth to age five, for early intervention. The model comprised two major components:

  • Introduction and systematic integration during selected well-child visits of a formal, standardized developmental screening tool that was both practical and effective.
  • Collaboration with local and state agency staff and families to design a local system for identifying and serving children more effectively.

Over the years, lessons learned from the pilot prompted key changes in North Carolina’s Medicaid policy to address developmentally challenged children more successfully. For example, the State now requires the use of a formal, standardized developmental screening tool at the following well-child EPSDT (Early, Periodic, Screening, Diagnosis and Treatment) visits: six months, 12 months, 18 or 24 months, 36 months, 48 and 60 months. The service must also be identified on the claim with a separate procedure code.

Tools to support families and practices in providing this service also were developed as part of the model. Parental tools included anticipatory guidance materials as well as promotional items to help inform and motivate parents (e.g., growth charts and refrigerator magnet reminders). For providers, we designed and distributed a comprehensive office resource guide that included both the research and "how to" of integrating screening and referral into their workflow. The guide also included sample posters that could be placed in exam rooms, pocket guides about developmental issues, and cards with suggested talking points to use when discussing referrals.

The following items are relevant to Community Care’s ABCD initiative:

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is a slow progressive lung disease that includes chronic bronchitis and emphysema. Tobacco smoking is the leading cause of COPD, and 15-20 percent of all smokers develop clinically significant COPD. The fourth leading cause of death in the U.S., COPD affects approximately 10 million adults and many more that have the disease but have not been diagnosed. The economic burden of the illness is great. COPD health care costs nearly 2.5 times as much as asthma with an annual financial impact of $37.2 billion. Of the direct medical costs of COPD, hospital expenses account for more than half of all costs (National Committee for Quality Assurance). For the North Carolina Medicaid program, COPD patients are 4.7 times more costly than the average Medicaid recipient.

In 2006, Community Care began a COPD Disease Management Program as a pilot initiative in response to a legislative directive to expand disease management programs as well as network and provider interest in COPD. The COPD pilot initiative utilizes a Disease Management Model based on Community Care’s Asthma Disease Management Program. 

COPD Pilot Summary

Five networks elected to pilot the COPD initiative. The following best practice guidelines were chosen for the initiative:

The following tool was developed as a part of the pilot:

The COPD program participants chose the following process performance measures derived from the annual chart audits:

  • Stage of the disease is documented (mild, moderate, severe or very severe).
  • Spirometry (pulmonary function testing) testing completed, including the last spirometry readings.
  • Use of appropriate medications (includes classes of COPD medications prescribed).
  • Action Plan completed.
  • Flu vaccine offered annually.
  • Pnemovax vaccine documented.
  • Smoking cessation counseling documented.

The following outcome performance measures derived from claims data were chosen:

  • ED visits for COPD exacerbations.
  • Hospitalizations for COPD exacerbations.
  • Medications (drug types and costs of filled medications).

In addition, program participants included a quality-of-life tool as a qualitative measure.

Practice and Provider Supports for COPD

In addition to the materials listed above, Community Care helped support networks implementing the COPD initiative in a number of ways:

Stroke Prevention Pilot Initiative

Supported by a grant from the Kate B. Reynolds Foundation, three networks participated in this pilot effort which started in 2008. The goal of this pilot was to identify individuals with hypertension and to focus on a sub-set of those individuals who have a history of not controlling their hypertension and aim to prevent a stroke from uncontrolled hypertension.  Practices with larger numbers of Medicaid patients with hypertension were chosen.  These practices received more intensive provider education, chart audits and performance feedback. The higher-risk subset of patients (those with a history of poor medication adherence and co-morbid cardiovascular risk conditions) received an additional telephonic care management intervention.

Early lessons from the pilot included the need to better budget and support the technical component of the telephonic patient self-management support program. Nurse care managers found it cumbersome for the telephone intervention software to sit outside of the web-based case management tool they are accustomed to using (CMIS). Lack of integration required double entry of data, and made it impossible for other staff members to assist the designated nurse care manager.  The nurses also found that this is a difficult population to engage (patients with historically poor adherence to medication may not be the ones most “ready and willing” to participate in this program). Also, patients with hypertension are often still active, and difficult to catch at home during working hours. A significant number of patient phones were disconnected during the program period.

Program Summary for Stoke Prevention

Our provider education and practice support activities included the following:

  • Baseline and follow-up chart audit results (performance evaluation and feedback).
  • We developed and distributed evidence-based guidelines and practice tools to support patient-provider conversations about cardiovascular risk reduction to pilot practices as well as other Community Care practices; in addition, we have posted them on our website for public use.
  • Strategies for physician/practice education varied based on local resource availability and the preferences of participating practices. These activities included “lunch and learns,” academic detailing, distribution of patient and provider educational, review of evidence-based treatment guidelines pertinent to cardiovascular risk reduction, community forums and quality improvement process support.

In the category of patient education and self-management support, the Community Care team coordinated the following activities.

  • We developed a software program that uses Medicaid claims data to: (1) identify recipients with poor adherence to their blood pressure medications, and (2) stratify them by risk according to co-morbidity data. This program makes real-time automated reports available to all Community Care networks that alert network pharmacists and case managers about patients with poor adherence as well as an indication of risk factors (hypertension, prior heart attack, stroke, ischemic vascular disease and diabetes).
  • Working collaboratively with the Duke VA Center for Health Services Research, we developed for the pilot networks an interface between this program and an intervention tool for case managers. Eligible patient lists were updated weekly to identify whether the patient had co-morbid conditions of diabetes or ischemic vascular disease, and to identify  the patient’s historical medication possession ratio for blood pressure medications. These factors influenced the prioritization of eligible patients for outreach by a care manager. Care managers contacted patients by mail or phone to invite them to participate in the program. The program asked care managers to call patients at least 10 times over the course of six months (at approximately three-week intervals) and provide a tailored schedule of educational and behavioral support modules.  
  • Behavioral interventions were tailored to patients based on individual circumstances and needs such as the perceived risk of hypertension and side effects of hypertension medication therapy as well as a patient’s memory, literacy, social support system, and relationship with his or her health care provider.
  • Networks identified a range of local strategies to reach eligible patients and/or encourage participation in the program, including: outreach by mail or phone; soliciting referrals from primary care providers; and inviting eligible patients to participate at the time of hospital or emergency department discharge. Patient incentives included: home blood pressure monitors; mailed patient education materials; and patient self-management notebooks.

Lessons Learned in the Stroke Prevention Pilot

  • Care managers had an easier time engaging patients who were referred by providers or practice-based primary care managers, or those that had recently been in a crisis situation (e.g., recent cardiovascular event or hospital discharge).
  • Providing blood pressure monitoring to participants proved to be an important incentive both to patients and providers.
  • A talent for engaging patients and establishing trust and rapport over the phone is essential.
  • Future efforts to systematically change practice patterns will likely require a more intensive, interactive and sustained approach (an approach this is more resource-intensive than traditional provider education/CME).

Resources relevant to Community Care’s Stroke Prevention Pilot Program you may wish to access include:

Childhood Obesity Prevention Initiative

The childhood obesity prevention pilot was also supported by a grant from the Kate B. Reynolds Foundation in 2008.  The goal of this pilot effort was to create a replicable model that would improve the ability of practices to screen for childhood obesity and to implement processes to educate patients and their family about weight and nutrition management. Four networks participated in the program and worked with primary care practices and their Medicaid-enrolled patients between the ages of two and 18. A total of 121 primary care practices participated with their Medicaid patients ranging from five to 90 percent of their total patient population. Many practices were also safety-net providers that care for uninsured patients. At the end of the two-year pilot in June 2010, Community Care had trained half of the practices in the use of assessment tools, motivational interviewing techniques and linking practices to community resources for patient/family education. In addition, the pilot was committed to increasing the number of practices reporting the use of BMI (body mass index) screening. Final reports from the participating networks indicated that all of them met or exceeded those goals.

The childhood obesity program comprised three main strategies.

  • Target providers and primary care practices to increase BMI screening and improve self-efficacy in assessing patients for overweight and obesity. Community Care partnered with the N.C. Division of Public Health to develop provider toolkits based on evidence-based guidelines. These toolkits were distributed and providers trained in the use of these toolkits.
  • Community Care disseminated standard, evidence-based, family education messages about healthy eating and physical activity through its practices and case management network. The toolkits served as the basis for these messages and included simple education tools for patients and families. Providers and case managers were trained in the use of these tools and are expected to use them after the original grant period has ended.
  • Community Care worked to provide direct linkages between practices and relevant community resources. Participating networks compiled lists of community resources and distributed these to practices and providers with the toolkits.

Key outcomes of the childhood obesity project included the following.

  • The networks reported that 54 to 100 percent of their practices (83 in total) were trained in the use of obesity screening tools. This figure represents 83 percent of the total participating practices, which exceeded the initial goal of 50 percent. These trainings included formal CME sessions with experts in pediatric obesity prevention and treatment, updates during local provider meetings and face-to-face visits to practices when providers were unable to attend formal sessions.
  • The networks reported a range of 60 to 100 percent of practices (105 in total) with established links to community resources for patient and family education. Accordingly, 87 percent of participating practices received information about community resources, which exceeded our initial goal of 50 percent. At least one network posted this information on their website to ensure they could continue educating providers on resources available to patients.
  • The networks reported a range of 60 to 100 percent of practices (77 in total) that used BMI screening (note: this figure is an estimate as some practices did not complete a post-needs assessment). This is an increase from the number of practices that reported using BMI screening tools during the pre-assessment.

The participating networks learned that promoting patient behavior changes is a complex process that requires motivational interviewing skills. In addition, the ability to co-locate nutritionists in private practices was found to be helpful in meeting with patients and their family, and targeting the educational sessions. As a result of this pilot, participating networks have strengthened their connection with community resources (one medical director put it, “it takes a village to slim a child”). Participating networks also have partnered with county extension agencies, public health departments, local parks and recreation agencies, and local advocacy groups to decrease the burden of obesity.

Resources relevant to Community Care’s Childhood Obesity Pilot Program you may wish to access include:

Piloting initiatives has proved valuable in the Community Care program.  It enables a smaller set of engaged networks and providers to test model components and determine which elements are essential to succeed and achieve the desired outcomes.  The replication process is facilitated by tools and processes already tested and implemented in other network settings.