Organizations look beyond cookie-cutter case management initiatives
Executive Summary
Recognizing that case management programs should be tailored to the special populations being served, health plans are creating specialty programs to meet the needs of their members.
• Pediatric case managers at UPMC for You collaborate with caseworkers to ensure that children in foster care receive well-child visits and dental check-ups and other healthcare services they need.
• CareSource’s substance abuse program provides case management for members who are receiving multiple prescriptions for narcotics from multiple providers.
• Native American members in Molina Healthcare’s Medicaid managed care plan may apply for a stipend to cover traditional healing.
An individual approach improves results
When it comes to case management, there’s no such thing as one-size-fits-all. What works for one person may not work at all for another. And, often, what works for one group of people doesn’t work so well for another group.
"Population management is a term often used to identify what might be effective when we are working with individuals who have the same diagnosis, such as heart failure or diabetes. But even within these defined population groups, there are unique differences among the individuals with that diagnosis. The true art of case management is in the creation of individualized programs to meet the very unique needs of the individual," says Catherine Mullahy, RN, BS, CRRN, CCM, president of Mullahy and Associates, LLC, a Huntington, NY-based case management consulting firm.
She points out that the case managers routinely use evidence-based guidelines to promote improved outcomes, but that’s often not enough.
"The real contributions that case managers can make go way beyond a standardized connect-the-dots approach to managing care. Educational, cultural, or religious differences cannot be viewed as barriers, but rather as opportunities to truly understand a patient population and then individualize the approach that we will use to help them maximize their health," she says.
Case managers need to acquire an understanding of the cultural beliefs of people with whom they interact, take into consideration their behavioral health needs as well as medical needs, and recognize the challenges that patients face in their everyday lives in order to effectively manage their care, Mullahy says.
Health plans and providers have recognized the value of fitting their programs to the specific needs of the populations they serve. They are going beyond the typical case management programs and are creating specialty case management initiatives designed to improve the health of specific patient populations that might not benefit from traditional case management.
For instance, pediatric case managers at UPMC for You work with caseworkers from each county’s Department of Children, Youth and Families to see that children in foster care receive well-child visits to a pediatrician or family practitioner, are up on their immunizations, and have dental check-ups.
"We believe this is a population that needs a lot of help with healthcare, and we are committing the resources to see that they get it," says Laura Fennimore, RN, DNP, a clinical director who oversees pediatrics for UPMC Health Plan. UPMC for You is the Pittsburgh-based health plan’s Medicaid managed care plan. (For details, see article on page 63.)
The challenges that children in foster care experience early in life have an impact on their overall health as they go into adolescence and adulthood, Fennimore says. "When you take into consideration the long-term impact on the health of the individual and the cost of caring for people over the course of a lifetime, making sure these children get the healthcare services they need is well worth the effort and expense," she says.
When CareSource looked at ways to help their members who were abusing controlled substances overcome their addictions, the Dayton, OH-based Medicaid managed care plan decided to have RN case managers work with the members and support them as they struggled to give up drugs. "We tried other approaches in the past, but we didn’t have the positive outcomes that we have in this program," says James Gartner, RPh, MBA, vice president of pharmacy and medication management for CareSource.
The case managers work closely with the members who enroll in the program for 18 months and collaborate with the physicians who are prescribing medications for the member.
"Our program is unique because nurse case managers hold the hands of our members as much as needed and help them get into a better situation. We are a member-centric health plan, and this is just one of the programs we have developed to help our members," Gartner says. (For details on the program, see page 64.)
Molina Healthcare’s Traditional Medicine Benefit allows its Native American members to use traditional healing to complement Western medicine. Members in Centennial Care, Molina’s Medicaid managed care plan, can apply for a stipend of up to $200 to pay for the cost of traditional care, such as herbal treatments or sweat lodge ceremonies. (For details, see related article on page 66.)
