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
AmeriChoice
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.
