Indiana Chronic Disease Management Program (ICDMP)

In 2003 the Indiana Office of Medicaid Policy and Planning (OMPP) introduced the Indiana Chronic Disease Management Program (ICDMP), designed for people with diabetes or congestive heart failure (CHF), or both, in its Aged, Blind, and Disabled Medicaid population. Program interventions were developed by the Indiana OMPP using an approach consistent with the Chronic Care Model. This was it's website for a number of years.

October 12, 2005


INDIANAPOLIS---Indiana’s Family and Social Services Administration (FSSA) and State Department of Health (ISDH) announce the latest evaluation results of their jointly managed, nationally-recognized Indiana Chronic Disease Management Program (ICDMP). The program provides support and information to Hoosiers with chronic illnesses so they can better manage their conditions and improve their quality of life. Jeanne LaBrecque, FSSA’s Director of Medicaid and Health Policy, explained, “The program empowers patients to take better control of their health care. As a result, we have seen decreases in hospitalizations, fewer expensive crises, and a potential for further cost savings overall.”

ICDMP addresses diabetes, congestive heart failure, asthma, and chronic kidney disease. In order to appropriately manage their conditions, the program’s unique methodology identifies members’ needs and classifies them accordingly into either the call center or individualized nurse care management services. The call center services are calls to members that focus on different topics, including a health assessment, medications, nutrition, and exercise; which are also supplemented with educational mailings. The nurse care management services provides nurse care managers who meet with members to educate them about their specific conditions and to help set self-management goals. The nurse care manager may also accompany the patient to a physician’s appointment in order to help reinforce the relationship between the member and his or her primary medical provider

The program provides support to physicians, as well as to patients. Providers can refer their Medicaid patients to the call center and nurse care management for the ICDMP services. They also receive toolkits containing clinical guidelines, flow sheets, and educational materials; and, are invited to participate in collaborative learning sessions. State Health Commissioner and Medicaid Medical Director, Judith A. Monroe, M.D., described, “We are on the right track by including primary care in the equation. One of our next steps is to find ways to further engage physicians in the battle against chronic diseases.”

Add One

To gauge the program’s success in improving health and saving money, the state consulted Regenstrief Institute, a non-profit health care research organization affiliated with the Indiana University School of Medicine. Regenstrief helped the state design a management programs. The RCT compared two groups of Medicaid members eligible for ICDMP. Both groups were equal in variables; except one group received the intervention and the other did not. “Comparisons made in a RCT are more likely, than those made in weaker evaluation designs, to be attributable to the ICDMP, and are somewhat less likely to reflect unrelated outside factors,” explained Dr. Thomas Inui, President and CEO of the Regenstrief Institute.

The RCT studied patient behavior, hospitalization rates, drug utilization, and member satisfaction, in addition to multiple other cost and quality indicators from September 2003 to May 2005. It revealed that most significant results were found in the population per member per month. When projected to the entire program, the findings indicate ICDMP could generate a savings as great as $29 million.

For more information, visit the ICDMP website at, or contact Kathy Moses, Director of Disease Management (FSSA), at 317-233-8800 or T.J. Lightle, Director of Office of Public Affairs (ISDH) at 317-233-7315.


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.

For more information regarding the Indiana Chronic Disease Management Program, please contact the Call Center at 1-866-311-3101.