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Service Delivery Innovation Profile

Medicaid Plan-Sponsored Support of Case Managers Serving High-Cost Enrollees With Substance Abuse Disorders Enhances Access to Services Without Increasing Costs


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Snapshot

Summary

A Medicaid managed care plan provides ongoing support to nurse case managers to better enable them to coordinate and manage the care of high-cost enrollees with co-occurring medical conditions and substance abuse disorders. Historically, these nurse case managers had only standard nursing school education on substance abuse issues and no special experience and knowledge to address substance abuse issues. Case managers participate in bimonthly, interdisciplinary, case-finding conferences in which they discuss various issues related to substance abuse disorders and treatment, and learn and practice important skills to serve this population (e.g., motivational interviewing). Case managers use the knowledge and skills to serve patients through face-to-face meetings and telephone calls designed to ensure that patients recognize the addiction problems they face, have access to the treatment and services they need, and consider changing lifestyle behaviors to improve health status. The program enabled nurse case managers to feel more confident and competent in dealing with substance abuse issues, increased communication across providers, and enhanced access to case management and substance abuse services, without significantly increasing costs.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of a comparison study of an intervention group of 400 high-cost members with substance abuse disorders to a control group of 203 similar adults with comparable adjusted clinical group case-mix risk scores; the study evaluated trends in access to care, inpatient and ED use, and total per-member, per-month costs during the 2-year study period, with measures being taken at baseline and after years 1 and 2.
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Developing Organizations

Johns Hopkins HealthCare
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Date First Implemented

2004
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Patient Population

Vulnerable Populations > Co-occuring disorders; Insurance Status > Medicaid; Vulnerable Populations > Substance abusersend pp

Problem Addressed

Many high-cost Medicaid managed care enrollees have one or more chronic medical conditions along with substance abuse disorders. Traditional care management programs use nurses trained to deal primarily (if not exclusively) with medical conditions, thus limiting their success in enhancing outcomes and reducing costs for these patients.
  • Many substance abuse disorders among high-cost Medicaid enrollees: The Medicaid managed care plan at Johns Hopkins HealthCare's Priority Partners found that roughly half of the enrollees that were expected to be high cost in the future (using predictive modeling) had underlying substance abuse disorders. In addition, 45 percent of those enrollees readmitted to the hospital shortly after discharge also had substance abuse disorders.
  • Need for substance abuse training: Like their peers at many other Medicaid managed care plans, nurse case managers at Johns Hopkins HealthCare lacked specialized training on substance abuse disorders, and thus did not feel comfortable addressing them in their patients. As a result, they tended to focus almost exclusively on appropriate care management and coordination only for their patient's medical issues.

What They Did

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Description of the Innovative Activity

Johns Hopkins HealthCare provides ongoing support to nurse case managers in the Priority Partners Medicaid managed care plan to better enable them to coordinate and manage the care of high-cost enrollees with co-occurring medical conditions and substance abuse disorders. Case managers participate in bimonthly, interdisciplinary, case-finding conferences and monthly, departmental clinical conferences in which they discuss and learn about various issues related to substance abuse disorders and treatment, and learn and practice skills important to serving this population. Care managers use the knowledge and skills in serving patients through face-to-face meetings and telephone calls designed to ensure that patients recognize the addiction-related problems they face, have access to the treatment and services they need, and consider changing lifestyle behaviors to improve health status. Key program elements include the following:
  • Predictive modeling to identify high-cost cases: Johns Hopkins HealthCare uses a predictive modeling system (based on the Johns Hopkins University Adjusted Clinical Group Case-Mix software) that analyzes claims data (e.g., gender, age, diagnoses) to identify enrollees likely to be in the top 5 percent of expenses over the next 12 months. As noted, many of these patients have both medical morbidities (e.g., diabetes, chronic obstructive pulmonary disease, congestive heart failure, low back pain) and substance abuse disorders, including addictions to alcohol, prescribed opiates, heroin, or cocaine. During the initial 2-year trial, Johns Hopkins HealthCare identified 603 high-cost enrollees with both medical conditions and substance abuse disorders, with 400 being assigned to the intervention group and 203 to a comparison group. The intervention enrollees all lived in the city of Baltimore, Baltimore County, and Prince Georges County, MD. The comparison enrollees were from other Maryland counties. Since the trial ended, the same approach has been used to identify high-risk enrollees in other geographic areas and populations. (See the Planning and Development section for more information on how the program has expanded.)
  • Bimonthly case conferences: Twice each month, nurse case managers, medical directors, psychiatrists with substance abuse training, other behavioral health staff, administrative leaders (as available), and other relevant health plan staff come together to present, review, and discuss specific, representative cases of high-cost patients with both medical conditions and substance abuse disorders. The group comes to consensus on recommendations for the patient. This ongoing process is designed to change the underlying culture (including the "silo" mentality that separates medical and substance abuse care) within the plan, particularly with respect to the following: enabling nurse case managers to understand the need to address substance abuse disorders; building trust and rapport among behavioral and medical care team members; and encouraging communication and dialogue across team members. The initial, 2-year trial focused on supporting eight nurse managers who served the geographic areas where the highest-cost patients lived (in and around Baltimore). Since that time, additional case managers serving other target geographic areas and populations have received support.
  • Departmental clinical conferences: In addition to the bimonthly sessions, monthly departmental conferences cover various topics related to medical and/or psychiatric conditions, such as drug addictions and interactions, drug treatment programs, and the diagnosis, evaluation, and management of chronic pain and depression (e.g., two sessions covered the use of depression screening tools). In addition, nurse case managers and behavioral staff receive education and training on specific skills, such as motivational interviewing, that can help in serving their patients.
  • Case management services: Case managers contact and provide ongoing services to high-cost enrollees with underlying substance abuse disorders, using the knowledge and skills learned in the bimonthly case conferences and monthly departmental meetings. These sessions, which take place in the patient's home, at a doctor's office, or (most frequently) by phone, are initially held fairly often, with frequency generally diminishing over time, usually plateauing at about 1 to 2 hours of face-to-face or phone interaction each month. During the sessions, case managers focus on assisting the patient in understanding how his or her addiction affects everyday life, and how that life might be better if the addiction could be cured. For example, a case manager working with an addicted grandmother might focus on how substance abuse negatively affects the grandmother's relationship with the grandchild she cares for while the mother works. This personalized and motivational interviewing approach is intended to help the patient recognize the addiction and understand its personal costs and benefits to them, which is the first step in convincing individuals to enroll in services (e.g., 12-step program, methadone program) that can help.
  • Real-time, cross-team access to information: The plan's information system provides case managers and other providers involved in both behavioral health and medical care with real-time access to each other's patient notes. This information, previously not available to the case managers or care team, helps to ensure that patients receive appropriate, coordinated care.

Context of the Innovation

Priority Partners is one of seven plans that participate in Maryland's Medicaid managed care program, which provides plans with a fixed per-member, per-month fee to cover both medical and substance abuse services (mental health services remain a carve-out, with a separate payment stream). The plan serves more than 150,000 members. Priority Partners is a 50/50 partnership of Johns Hopkins HealthCare LLC (which, in turn, is a partnership of Johns Hopkins University School of Medicine and the Johns Hopkins Health System) and Maryland Community Health System, a group of Federally Qualified Health Centers in Maryland.

Historically, case managers at Priority Partners had little or no experience in treating substance abuse disorders other than exposure in course material and training in nursing school. In fact, because such disorders were thought to interfere with traditional medical care management, enrollees with substance abuse diagnoses were excluded from the care management program. Roughly 5 years ago, the vice president of care management at Johns Hopkins HealthCare began to challenge this conventional wisdom, urging the plan to begin integrating substance abuse services into the program. In July 2004, the Center for Health Care Strategies, Inc., and the University of North Carolina School of Public Health (with support from the Robert Wood Johnson Foundation and Commonwealth Fund) launched a program known as the Business Case for Quality in Medicaid Managed Care, which sponsored and tested 10 initiatives (including this program) to gauge their impact on quality and costs.

Did It Work?

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Results

The program made nurse case managers feel more confident and competent in dealing with substance abuse issues, increased communication across providers, and enhanced access to case management and substance abuse services, without significantly increasing costs.
  • More confident, competent case managers: In a qualitative survey conducted after program implementation, nurse case managers expressed more confidence and indicated they felt more competent in addressing substance abuse issues in patients.
  • More interteam communication: Anecdotal feedback suggests that nurse case managers, medical providers, and behavioral health providers have increased communications with each other about patients as a result of the program.
  • Enhanced access to services: The percentage of participants receiving case management and/or substance abuse services increased during the 2-year trial, while use rates for these services remained flat in the control group. For example, the percentage of participants with access to disease management services rose from just over 10 percent at baseline to between 30 and 40 percent during the 24-month period after implementation; by contrast, access to these services remained below 10 percent over this time period for those in the control group. In addition, per-member, per-month pharmacy costs rose among participants but fell in the control group, suggesting that the program enhanced access to appropriate medication therapy.
  • No meaningful increase in costs: Although total care costs in both groups rose during the 2-year trial period, the increase was $30 per member per month less in the intervention group. Both groups experienced a decline in inpatient and emergency department (ED) use. Extrapolating from the $30 per-member, per-month figure, program leaders estimate total 2-year savings of $223,320, slightly below the $237,318 in program operating expenses over the same period (this figure excludes one-time start-up expenses of $40,276). In other words, the program generated savings on medical care that equaled roughly 94 percent of program operating expenses, meaning that the quality improvement gains generated came at a very modest expense.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of a comparison study of an intervention group of 400 high-cost members with substance abuse disorders to a control group of 203 similar adults with comparable adjusted clinical group case-mix risk scores; the study evaluated trends in access to care, inpatient and ED use, and total per-member, per-month costs during the 2-year study period, with measures being taken at baseline and after years 1 and 2.

How They Did It

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Planning and Development Process

Key elements in the planning and development process included the following:
  • Development of training curriculum: The director of research at Johns Hopkins HealthCare developed the initial training curriculum based on his experience as a clinical psychologist and feedback from nurse case manager and others in the field. The curriculum is modified on an ongoing basis in the case conferences and departmental clinical meetings in response to the specific information needs of participants.
  • Recruitment of nurse case managers: Because Priority Partners had identified a specific geographic population to be served, nurse case managers who served those areas were required to participate in the initiative. Although some initially resisted (voicing a preference to oversee only medical care), most quickly became engaged in the program after participating in a few of the case conference sessions.
  • Program expansion and curriculum evolution: Once the initial 2-year trial ended, Priority Partners expanded the program to new target geographic areas and populations, including the Eastern Shore of Maryland, at-risk pregnant women, individuals with substance abuse disorders and diabetes, and those recently discharged from the hospital with substance abuse problems. Case managers serving these areas/populations now participate in the bimonthly case conference sessions. The curriculum for these sessions has also evolved and expanded to include lifestyle issues and behaviors that relate to health, such as exercise, nutrition, and sleep habits. This evolution represents a natural transition from behavioral health to other types of behavior linked to health and well-being.

Resources Used and Skills Needed

  • Staffing: The initial 2-year program involved eight case managers along with other relevant staff who participated in case conference discussions as part of their regular duties. No new case managers were hired for the program, as Priority Partners limited participation to the number of patients that could be handled by existing staff. Nurse managers typically serve 60 to 80 patients. As noted, the program has expanded to other sites, where additional case managers and staff participate as part of their regular duties.
  • Costs: Total costs during the 2-year trial were $277,594, including $40,276 for startup and $237,318 in operating expenses. As noted earlier, savings generated by the program helped to recoup roughly 94 percent of operating expenses.1
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Funding Sources

Center for Health Care Strategies, Inc.; Robert Wood Johnson Foundation; Commonwealth Fund; University of North Carolina (UNC) Chapel Hill School of Public Health
The initial 2-year pilot was funded in part by a $50,000 grant from the Center for Health Care Strategies, Inc., under the Business Case for Quality in Medicaid Managed Care program sponsored by the Robert Wood Johnson Foundation and Commonwealth Fund. The University of North Carolina School of Public Health evaluated the initial 2-year trial as part of its participation in the program. Since the trial ended, Johns Hopkins HealthCare has funded the initiative internally. end fs

Adoption Considerations

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Getting Started with This Innovation

Secure case manager buy-in (to extent possible): Although Johns Hopkins HealthCare required its case managers to participate, initial participants ideally should be voluntarily recruited by sharing information on the rationale for, and potential benefits of, the program. Over time, most case managers—even those "drafted" to participate—will learn to appreciate the ongoing information and support provided by the program.

Sustaining This Innovation

  • Engage clinicians and other caregivers: This program represents a significant culture change for primary care physicians, nurses, and behavioral health/mental health clinicians, who tend to view substance abuse separately from medical conditions. Involving all these stakeholders helps to ensure that this "silo" mentality changes over time.
  • Lobby state to avoid substance abuse carve-out: This program works only if the Medicaid managed care organization takes on the financial risk for both medical and substance abuse services. But many states currently "carve-out" substance abuse services, while others (including Maryland) may be considering doing so in the future.
  • Expand and evolve program over time: As noted, Priority Partners has expanded the program and the curriculum over time in response to the needs of new target populations.

Additional Considerations

This program may also be beneficial for commercial managed care plans that serve a significant population of enrollees with substance abuse disorders.

More Information

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Contact the Innovator

Peter J. Fagan, PhD, M.Div.
Associate Professor of Medical Psychology
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
(410) 424-4958
E-mail: pfagan@jhmi.edu

Innovator Disclosures

Dr. Fagan has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Greene SB, Reiter KL, Kilpatrick KE, et al. Searching for a business case for quality in Medicaid managed care. Health Care Manage Rev. 2008;33(4):350-60. [PubMed]

Greene SB, Kilpatrick K. Reiter K, et al. Better Payment Policies for Quality of Care: Fostering the Business Case for Quality Phase I - Medicaid Demonstration. Final Report--Site Summaries. October 2007. Prepared by The Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Available at: http://www.chcs.org/usr_doc/Optima_Health.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

Footnotes

1 Schuster A, Sylvia M, Stoller KB, et al. Measuring the Enhancement of Integrated Care Management of a Medicaid Population with Substance Abuse and High Medical Expenses: return on investment after two years. Poster Presentation, AcademyHealth Annual Research Meeting, June 2007, Orlando, FL.
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Original publication: November 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 03, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.