September 2004 Issue

In this issue we will be highlighting the Nurse Care Management component of the Indiana Chronic Disease Management Program.  It is an integral part of the program.  We are pioneers in developing a state supported model for nurse care management and want to ensure it is beneficial for all partners in the Indiana Chronic Disease Management Program.  Our goal is to make integrating nurse care management into your practice an easy PDSA cycle for all practices to implement.  Here is how to do just that:

Some Facts-

Ø      Nurse Care Management is provided to high-risk Medicaid patients in the Indiana Chronic Disease Management Program. 

Ø      High risk is determined by evaluating claims data for high utilization/high cost of services pertaining to a person’s chronic condition.

Ø      Medicaid contracts with the Indiana Primary Health Care Association (IPHCA) and the Indiana Minority Health Coalition (IMHC) for nurse care management services.

Ø      Medicaid assigns each organization counties across Indiana for patient coverage.

Ø      Each practice will only be assigned one nurse for their high-risk patients.

Ø      Practices may refer Medicaid patients to Nurse Care Management by calling 1-866-311-3101 or by using the form provided for nurse care manager referrals.

Ø      Patients are in nurse care management for 4 – 6 months.  The nurse will follow a patient with a combination of home visits, telephonic follow up and provider visits.

Ø      Nurses will work with patients to develop self-management skills so patients can become part of their care team and assist in managing their condition on a day-to-day basis.

Ø      Patient education and community resources are also a part of the nurse care management component.

Ø      Patients ‘graduate’ from nurse care management and are transitioned to the Call Center where they will receive quarterly educational calls on their condition.

Some Feedback-

Once a patient has graduated from nurse care management and before they are queued up for quarterly educational calls by the Call Center, these graduates are called to ensure their condition has remained stable.  During these calls, the patients are asked to give their impressions on their experience with nurse care management.  The following are just a few of those comments:

Ø      The member was happy the nurse care manager went along with her to her doctor’s appointment, she felt she was more prepared as far as the questions she had for the doctor.

Ø      The nurse care manager was quite pleasant, member feels better after working with the nurse on depression.

Ø      The nurse care manager helped the patient cut down on the amount of cigarettes he smokes in a day.  But member stated he was not able to stop smoking.

Ø      The nurse care manager brought issues concerning the member’s health to her attention like explaining the importance of checking her feet daily.

Ø      The member learned to log daily weights from the nurse care manager.

Ø      The member was happy that the nurse care manager called and checked on them.

Some Ideas for Implementation-

The following PDSA cycles have been submitted by the nurse care management organizations.

Ø      Establish a communication strategy between the practice and NCM-

o       Identify a contact person in the practice;

o       Identify the best form of communication- fax, email, phone call, etc.- between office and nurse and nurse and office.

Ø      Accomplish the Patient/PMP/NCM visit to the discuss the chronic disease management plan-

o       PMP office set up a planned chronic care visit for this occur

o       Consider a group visit with all of the nurse care-managed patients in the practice, nurse care manager, and PMP.

Ø      Incorporate the NCM reports to the PMP into the patient’s chart-

o       Establish a process for the reports to be attached to the patient record

o       Establish a review process so that information can be useful to the PMP.

Ø      Utilize the NCM’s role with the patient to accomplish the chronic disease management plan-

o       Contact the NCM to discuss the plan for the patient- ask for NCM’s assessment and insight.

Ø      Invite the NCM to existing Quality Improvement Meetings or Case Study Meetings-

o       Utilize existing meetings at the practice to include the nurse in developing strategies to integrate care management into the practice.

At the recent Learning Sessions in Bedford, Gary, and Indianapolis, practices were given the name of the nurse care manager assigned to their practice.  If you did not attend the Learning Sessions and want to know whom your case manager is, please call the Help Desk at 866-311-3101.


IPHCA- 317-630- 0845 – Lisa Winternheimer

IMHC- 317- 926-4011 – Lisa Miller contains program materials and information on chronic disease.

1-866-311-3101 Help Desk- for CDMS or general program questions.

1-317-234-2760 – Mary Jo Golubski – Collaborative and program support.

1-317-233-7346 – Kathy Moses – Medicaid Chronic Disease Director


Teleconference Call on October 7, 2004 at noon Indianapolis time.  Call in number 1-888-830-6260 Participant Code- 884713.  The call is for all collaborative participants to share where they are with implementation of the program and ask for assistance/ideas with barriers.