Prevention is key

JEFFERSON CITY -- Nina Stewart tells the story of a diabetic whose chances at achieving a healthy lifestyle have been increased through the aid of a healthcare coach.

Her story is an example of the new direction Missouri is taking with its program to provide health care coverage for the lower income -- the federal Medicaid program renamed, in Missouri, to Mo HealthNet.

"A coach recommended to the patient the use of a food diary to help monitor blood sugar levels, now the patient will have good news to deliver to the physician, instead of just bad news," Stewart said.

Stewart, a registered nurse with over 30 years of experience, is one of the healthcare coaches recruited by the state to implement the Chronic Care Improvement Program (CCIP), aimed at improving the health of Mo HealthNet participants suffering from at least one of six chronic illnesses: diabetes, asthma, chronic bronchitis and emphysema, acid reflux disease, heart disease, and sickle-cell disease.

"The reason we call it a chronic care program is because in the past folks have just focused on a single disease, and not many of us are fortunate enough to have just one," said George Oesterick, Deputy Director of Mo HealthNet Division of Clinical Services. "Often, if you have diabetes, you end up with lipid disease or you end up with cardio-vascular disease."

According to George Oesterick, CCIP is the possible backbone for the new Mo HealthNet program.

Candidates get a "ticket in" because of the disease. They are contacted by a coach, informed of their eligibility in the program at no additional cost, and given the option of "opting out" if they do not wish to participate.

Stewart works in conjunction with a growing team of 13 health care coaches, along with disease management and care coordinators and account managers fielding calls from participants, providing education and guidance. The call up service is available 24 hours a day and 7 days a week.

All the health care coaches working on the program are RN's, a qualification Stewart says is central to the role of the coach.

"They interact directly with the patient and reach out to them, take calls from them, help them coordinate their office visits, their referrals, determine if they need transportations to visits provided under Medicaid," Oesterick said.

Stewart said that the most tremendous benefit of a healthcare coach is that they are able to have a behavioral interaction to offer self-empowerment to patients to take charge of their health.

"Our role is to help them to find a piece of information concerning their health care," Stewart said. "We are interested in how primary physicians can deal with health care challenges."

About 140,000 of the state's 825,000 Medicaid recipients are eligible for CCIP. To date, 53,000 patients have been enrolled, the program is being rolled out section by section in the state.

Currently, the I-70 corridor along with the northeast and the southwest regions of the state have been reached, said Amy Woods, deputy director of Pharmacy and Clinical Services in the Mo HealthNet Division .

The remaining 80,000 eligible participants are scheduled to be enrolled by June 30, 2008, said Sara Anderson, spokeswoman for the Social Services Department.

CCIP is the state's first electronic-based plan of care, where a computer tool is used to compile health care expenditures, diagnosis on health care claims, and procedure codes from Medicaid recipients in the past year to create a ranking of high risk, medium risk and low risk patients, Oesterick said.

The idea behind the electronic medical records approach is that it will enable providers, healthcare coaches, and patients to collaborate -- the concept being that health and state costs can both benefit from a more coordinated approach that focuses on a person's overall lifestyles rather than specific medical symptoms.

"We know that around 80 percent of health care costs are dedicated to about 20 percent of patients, that is the concept behind CCIP" said Karen Edison, co-director of the Center of Health Medicine at the University of Missouri-Columbia.

The state's Social Services Department contracted with a APS Healthcare, a private firm in Maryland that specializes in care management and behavioral services, to recruit the coaches and implement the health management system.

So far, the contract with APS has cost the state $ 6.75 million -- including both implementation costs as well as per member per month fees.

The cost per member per month is $15.81.

CCIP is not mentioned specifically in the legislation earlier this year that replaced Medicaid. However, the guidelines of the new program require that each recipient create a health improvement plan and have a health care home.

Ilalyn Irwin, a clinical instructor for healthcare policy at the University of Missouri-Columbia, said that the idea of CCIP is a step in the right direction, but that the population it is aimed toward is a difficult one to manage.

"If you set up measures that don't make sense to the patient, it won't be successful. In the health care plan, a patient is told to eat more fruits, but if you go into grocery store in a low-income neighborhood, you will know why this is hard; a patient is told to take a walk, but they live in an unsafe neighborhood. It's a catch-22," Irwin said.

Amy Woods said the challenges facing management of the Medicaid population was the impetus for the program.

"Historically, there have been some difficulties with making sure they get consistent care, to make sure they are doing what they need to do on a consistent basis," Woods said.

The success of the program will be monitored electronically, measuring whether a patient has successfully followed requirements in the outlined plan of care.

"The better educated these people are about their disease and treatment, the more responsive they will be in keeping up with their meds and doctors visits, preventing the disease from worsening if at all possible," Anderson, said.

Since it began in November, the program has been moving along at a rapid pace, Stewart said.

In addition to educating participants, Stewart said it is important to continue to meet the growing need as the participant base grows.

"We are still conducting interviews for coaches on a daily basis for a reason," Stewart said.

In Stewart's experience as a coach, very few patients eligible for the program have opted out, creating a need to constantly acquire new resources. Stewart said they are enrolling new patient in the program daily.

"Their enthusiasm is quite encouraging because so many of them feel that they have pieces of information about how to improve their health care. They are just happy to finally speak to someone on a one-to-one basis," Stewart said.