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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
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Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare

Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
As increasing numbers of children with special healthcare needs move into Medicaid managed care, health plans can improve care coordination using evidence from Medicare.
Our findings also point to the importance of defining the operational parameters of care coordination programs, such as caseloads, specific activities, and interactions with patients and family members. Defining these processes, and potentially specifying them in state Medicaid managed care contracts, provides an opportunity to subsequently measure them. In turn, measurement allows states and MMCOs to identify factors contributing to program outcomes. 

3. Encourage active engagement between care coordinators and primary care providers. Among Medicare care coordination programs that demonstrated positive outcomes, care coordinators were either embedded in practices as part of the primary care team or developed close working relationships with primary care physicians.20-23,26-29,32,35,45,46 Among interventions in the Medicare Coordinated Care Demonstration that had positive outcomes, care coordinators either had already worked with the primary care physicians or accompanied patients to primary care visits to establish a relationship. These care coordinators were able to effectively communicate with providers, sharing important and timely information while making limited demands on providers’ time.20 Having a personal relationship with the care managers was also associated with physicians having greater trust in, respect for, and willingness to work with the care coordinators. Care coordination interventions that did not involve collaboration with primary care providers generally did not demonstrate positive outcomes.20,31

Medicaid policy makers and MMCOs may wish to facilitate active care coordinator–primary care physician collaboration by reimbursing primary care practices for part of the cost of hiring dedicated care coordination staff. MMCOs that designate patient-centered medical homes may wish to support this staff investment as part of the medical home model. MMCOs that employ care coordinators to work across practices can also specify care coordination functions and performance requirements to ensure that the coordinators actively engage with the practices that they support.

4. Require some in-person contact between care coordinators and patients.Most care coordination programs that demonstrated positive outcomes involved substantial in-person contact between care coordinators or managers and patients, in addition to periodic telephone calls. In-person care included meeting patients at the primary care office (either during the primary care visit or separately) or making in-home visits and assessments, as well as visits during inpatient stays.20,22,26-28,31,35,37,45,46 The single exception to this was a Health Buddy intervention that involved primarily electronic contact between patients and nurse care managers over a telephonic device.23,44 Nearly all other telephone-only interventions for Medicare beneficiaries failed to generate favorable effects on utilization or costs.31

Medicaid policy makers and MMCOs may want to develop requirements for ongoing, periodic in-person visits. These visits may help to build strong relationships and trust among patients, their families, and care coordinators. In-person visits may also build strong patient engagement and capacity for self-management. For example, nurses may use techniques such as motivational interviewing during in-person visits to understand how they can guide caregivers to improve management of their child’s condition and, as appropriate, self-management by the child. State Medicaid programs and MMCOs need to develop oversight mechanisms to ensure that coordinators operationalize such requirements in a satisfactory way. In particular, requirements for in-person visits should not impose additional travel burdens on families; instead, they should emphasize seamless integration of care coordination with existing appointments or patients’ home routines.

5. Facilitate information sharing. Care managers or coordinators in several Medicare programs that showed positive impacts had access to the data in patients’ medical records, patient registries, and real-time data on ED use and hospital admissions to facilitate interventions during and not after crises.22,27,28 In other successful programs, the care managers served as information hubs in the absence of timely ED and inpatient data, coordinating the flow of information among multiple providers.20 Other programs noted that lack of timely information on hospital and ED use was a barrier to greater improvement in outcomes.25

One potential mechanism for information sharing is the use of a shared electronic health record (EHR) by primary care providers, specialists, and care coordinators. Interoperable EHRs may increase the effectiveness of care coordination; however, these are rare. In the absence of EHRs that are well configured for care coordination, states and MMCOs may need to develop or support other ways for care coordinators to facilitate information sharing between providers. For example, some states have established limited health information exchanges that allow for near real-time notification of ED visits and hospitalizations that could be used by care coordinators.

6. Supplement care coordinators’ capabilities with those of other clinical experts, as relevant. Many interventions with positive impacts involved other professionals to help care coordinators address patients’ needs related to medication management, behavioral health, and nonmedical services.20,22,27,28,39 For example, in several programs, social workers addressed unmet behavioral health care needs in tandem with care coordinators’ efforts. This likely increased patients’ abilities to engage with care coordinators and increased the effectiveness of the programs.22,27

Ensuring that care coordinators can help link patients to other clinical experts (eg, dieticians for children with feeding tubes and social workers for children with behavioral health problems) may be particularly important for CSHCN in Medicaid. Many CSHCN require services from medical, behavioral, and pharmacy providers, as well as services from other important entities (eg, early intervention programs or schools, juvenile justice systems, and social service agencies). States and MMCOs may want to leverage these clinical experts and deploy them as shared resources for care coordinators, regardless of whether the care coordinators are employed by practices, MMCOs, or other organizations. However, variation in the supply of pediatric providers, and in the social services available at the local and state levels, will affect care coordinators’ ability to marshal resources in this way.

DISCUSSION

This study describes 6 evidence-based program design elements from Medicare care coordination programs that provide potentially useful insights to help improve care coordination for CSHCN in Medicaid managed care. The available research on care coordination programs for CSHCN is limited as a source of evidence on effective care coordination practices, but the extensive Medicare literature can help address this gap. Based on these findings and discussions with experts in the field, state policy makers and MMCOs should consider the following when designing care coordination programs for CSHCN: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators’ expertise with that of other clinical experts.

As noted, adoption of these recommendations must be considered in light of some noteworthy differences between Medicare beneficiaries and Medicaid-enrolled CSHCN, such as the different constellations of diseases and conditions that they face and the types of services that they need.47 Care coordination efforts for CSHCN should also account for programmatic differences between Medicare and Medicaid. For example, it may be especially challenging for care coordinators to engage primary care providers in the Medicaid context due to Medicaid’s relatively lower payment rates for primary care services. 

It is also important to note that the Early and Periodic Screening, Diagnostic, and Treatment benefit package, which provides a potential vehicle for states to cover care coordination services for CSHCN in Medicaid, does not automatically provide any specific care coordination services or reimbursement for such services. States seeking to implement or improve care coordination for CSHCN via managed care must take care to include adequate funding for care coordination services in MMCO capitation rates, and state MMCO contracts should identify precisely how MMCOs will pay for and deliver care coordination services to CSHCN. 

An important design issue that was outside the scope of this study was the extent to which behavioral health care for CSHCN should be integrated within care coordination programs traditionally focused on physical health. Policy makers are increasingly recognizing the importance of addressing behavioral health needs in parallel with physical health needs for patients across the age spectrum. Several Medicare care coordination programs implemented team-based interventions that included social workers to address behavioral health needs or to facilitate referrals to more qualified behavioral health providers.22,27,28 Starting in 2017, Medicare began reimbursing primary care providers for behavioral health integration services based on the psychiatric collaborative care model,48 a model that was also effective in several pediatric populations with depression.49,50 However, the optimal balance between integration of behavioral health services within the primary care setting versus care coordination with behavioral health specialists for pediatric populations is an outstanding question. 

Limitations 

The review of the Medicare literature that informed this study was comprehensive but not systematic. We conducted a thorough search of references contained in the research syntheses and summary articles (a “snowball” strategy) and by pursuing references recommended by experts. This methodology was less structured than a systematic review but has been shown to serve as an effective strategy in searches of complex evidence.51 From our perspective, this strategy was also more efficient than a systematic review, particularly because there were many recently published syntheses and summary articles on care coordination. Nevertheless, it is possible that we excluded some relevant studies with this method. 

Another limitation is that we were unable to assess which combination of the 6 characteristics of effective care coordination programs relevant to CSHCN in Medicaid is necessary or sufficient for a program to lead to positive outcomes. The combination of characteristics required for “successful” care coordination programs for CSHCN may differ depending on program goals. 

 
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