The State of Montana Department of Health & Human Services recently issued an RFP to Rural, Community & Tribal Health Centers to establish or enhance health improvement services for Montana's Medicaid clients. The State has required that all staff with contracting organizations complete Chronic Care Professional (CCP) certification.
This Medicaid Health Improvement program builds on efforts by the Montana Medicaid Managed Care Bureau to improve care and reduce cost for Medicaid clients including medical home and external vendor disease management programs. According to the RFP issued on March 10, 2009, Montana defined their Health Improvement Program as including rigorous proactive clinical management along with intensive patient education, coaching, and monitoring. Health Improvement activities within this program will be delivered through a team approach including physicians, nurses, lifestyle coaches, mental health, preventative health, and health-monitoring support staff. The purpose of the Health Improvement Program is to improve quality of care and health outcomes for participating Medicaid patients as well as lower costs associated with preventable disease, unnecessary hospitalization and excessive emergency department use.
The new Health Improvement Program will not only focus on those already diagnosed with a chronic disease, but will also include health promotion and prevention. The goal will be to improve quality of care and health outcomes. The State will utilize predictive modeling software to identify and stratify the patients who are or will be high risk/high cost. Once the State has identified these patients, a list will be sent to each of the Centers based on the counties they have agreed to serve. The Centers will then contact patients in writing and by telephone to invite and encourage them to opt-in to the program. Once accepted into the program, the health center care manager(s) and lifestyle coaches will do a thorough assessment of the patient’s needs; assist them in establishing a “medical home”; establish a working relationship with the patient’s primary care provider; work with the patient to develop self-management objectives; educate the patient on available local services, supplies and equipment; and work with the State’s various prevention/education programs to make these resources available to appropriate patients.
The program re-design will allow the State to work collaboratively with existing Health Centers and their Satellites to vastly increase the number of available care managers and lifestyle coaches while maintaining the current budget. In addition, the care managers and coaches will be attached to Health Centers already serving low income and medically underserved communities. These centers embody a team approach to health care that can best accomplish the goals of the State to improve care and reduce unnecessary medical costs. This program will also continue its commitment to managing patients with chronic pain, introduce behavioral health improvement and identify and employ standards for managing high-risk pregnancy. RFP responses are due April 17, 2009 with contract awards tentatively scheduled for May 22, 2009.
Chronic Care Professional (CCP) certification has also been a centerpiece of Medicaid and Medicare chronic care improvement and systems change projects in states including Minnesota, Wisconsin and Vermont. The CCP program was first piloted in the State of Minnesota through funding from the Minnesota Department of Human Services in 2004 in partnership with a Minnesota health plan. Since that time, the program has been delivered in regional sessions throughout the state, with several hundred public health nurses, advanced practice nurses, and case managers completing certification. HealthSciences has also supported regional projects in New York and Minnesota to improve consumer engagement, evidence-based medical care, and disease self management, for over 100,000 patients with diabetes, coronary artery disease, heart failure, and depression. Targeted campaigns have focused on improving senior health and medication adherence.
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Blake Andersen, PhD,
