Origin and Goal of Program

Recently passed legislation requires the Office of Medicaid Policy and Planning (OMPP) to implement a disease management program for persons with diabetes, asthma, congestive heart failure, hypertension and recipients who are at high risk of chronic disease. 

 The goal of the Indiana Chronic Disease Management Program (ICDMP) is to build a comprehensive, locally based infrastructure that is sustainable and that will strengthen the existing public health infrastructure and help improve quality of health care in all populations, not just Medicaid recipients.  We hope that the ICDMP infrastructure will be an asset not only for the patient but also for healthcare providers. 

Components and Program Partners

 Centralized Telephone Call Center


Once members have been identified through Medicaid claims data as eligible for the program, they are stratified into two groups.   Members who are identified as lower severity will receive telephonic care management through a centralized call center.  The call center’s Care Coordinators will perform outbound calls to participants focused on conducting health assessments and providing educational materials to program participants.  Care Coordinators will also be available to accept participants’ inbound calls.  The ICDMP’s toll free help line is 866-311-3101.

Care Coordinators are non-clinical staff focused on customer service and member education.  They have a Bachelor’s degree and/or considerable customer service experience.  Care Coordinators receive extensive training on the appropriate disease states, medical terminology, call scripts and member education tools.  Many of the Care Coordinators currently serving this program have extensive experience in assisting members enrolled in Hoosier Healthwise or Medicaid Select.  Both the Call Center Manager and Trainer are registered nurses and are available to provide clinical support and advice, as necessary.

 Nurse Care Management Network

IN Primary Health Care Association (IPHCA)

 Members who are identified as higher severity will be assigned to a nurse care management network.  Nurses Care Managers will work with the Medicaid members’ primary medical providers to deliver a consistent message to members regarding management of their chronic disease.  Nurse Care Managers will also provide one-on-one assessments and education to participants for a 4-6 month intervention period and then for a 2-month reinforcement phase during which the participant will be transitioned to the call center for ongoing, quarterly assessments.

Nurses have achieved a Bachelor’s degree in Nursing and at least 1 year of experience in a community health setting or Bachelor’s work equivalent of a formal nursing certificate with at least 3 – 5 years of work experience in public health or chronic disease management.  The nurses currently working with the Indiana Chronic Disease Management Program have extensive experience with chronic illnesses in a variety of settings, including residential and home health care as well as family practices and clinics. They have developed expertise in several areas, such as cardiovascular rehabilitation, HIV, mental health services, long-term care, pediatrics/obstetrics, acute care, quality improvement, and case management. 

 Chronic Disease Management System (CDMS)

Mountain Pacific Quality Health Foundation (MPQHF)

To assist the care coordinators at the call center, nurse care managers, and physicians, the ICDMP has developed an Indiana-specific version of CDMS, an internet-based electronic medical record and information system electronic disease registry. CDMS will be used to enhance communication about the patient among the ICDMP partners involved in the member’s care as well as the member’s physician. CDMS will contain clinical as well as claims information on individual members, and will also be used to track health assessments, schedule patient contacts, and contain the Individualized care plans.

 Measurement and Evaluation

Regenstrief Institute

The ICDMP will be evaluated thoroughly for improved health outcomes and subsequent cost savings to the Medicaid program.  A prospective controlled study of the pilot program will be performed to assess health outcomes using CDMS as well as provider medical records.  A retrospective analysis of the statewide implementation will also be performed to determine impact on Medicaid costs as well as health outcomes.