Oklahoma's Medicaid program has had its fair share of issues, similar to many other state Medicaid programs. SoonerCare, as it is known, was facing increasing costs and had been ranked 49 out of all 50 states for clinical performance measures. The poor performance and high cost of the state-run program led the state legislature to form a task force in 2005 to find ways to improve SoonerCare's performance and efficiency.
"We had a vision to not view disease management as it had been viewed in the past," says Michael Herndon, DO, Sr. medical director of the Oklahoma Health Care Authority. "We wanted to focus on the person, not the disease, and wanted to teach members how to manage their own healthcare, not manage it for them."
The Oklahoma Health Care Authority contracted with Telligen, a West Des Moines, Iowa-based population health management firm, to create SoonerCare's Health Management Program. The program, which launched in February 2008, has saved Oklahoma's Medicaid program $139.2 million over four years, according to recently released data. The program did so by taking a two-pronged, comprehensive approach to population health management. Telligen completed its initial contract with the Oklahoma Health Care Authority June 30.
Care management
The first focus of Telligen's program with SoonerCare was care management for high-cost and high-risk members.
This patient-focused area of the plan revolves around the activity of licensed nurses who served as care managers for a set of patients. The care managers visited some patients — those with the highest risk scores — in their homes, while others checked in on patients over the phone. "It's a patient-centric program focused on the needs of individual patients," explains Mike Speight, vice president of state healthcare solutions at Telligen. "It is focused on individual needs and individualized care plans."
The care managers were recruited from all areas of Oklahoma. Telligen looked for some specific traits in the nurses who were to head this part of the program: knowledge of the Medicaid population, experience in primary care settings and familiarity with care management tasks, for example. Another important skill for the care managers is motivational interviewing, a technique for interacting with individual patients to help facilitate change, according to Mr. Speight. All Telligen care managers in the program were trained in motivational interviewing.
SoonerCare's care management program had a team of nurse care managers visiting patients face-to-face as well as a team of care managers working over the phone with patients. Over the course of four years, those nurses worked with a total of 20,000 patients to help them improve their self management and get motivated to make healthy choices and improve their overall health.
Practice facilitation
The second arm of the program focuses on redesigning workflows in primary care physician offices and promoting adherence to evidence-based clinical guidelines. Registered nurses serving as practice facilitators were deployed into physician offices for six to eight weeks to work with physicians and care team members on making those changes.
The program was voluntary for participating physicians. Practice facilitators set up informational meetings with practices, and the facilitators would go in to do a preliminary analysis only at the practices that expressed interest in the program, according to Mr. Speight.
The results of the analysis showed that many offices were only 20- to 30-percent compliant with clinical-based guidelines. "They were shocked, and in many cases embarrassed, but motivated to change," Mr. Speight says. "Quality improvement and system redesign skills are not taught in medical school," he says, making the practice facilitators necessary.
The practice facilitators worked with the physicians and their care teams in their offices to make the change easier. "There's a high emphasis on face-to-face communication," says Jeff Chungath, Telligen's CEO. "It's not done through printed or online material in hopes the [physicians] would change."
"We provide those boots on the ground for extended periods of time…to help physicians and other provider types — PAs and ARNPs — get better," agrees Mr. Speight. "Giving data doesn't suggest a solution, [physicians] need support and technical assistance to make a change in practice."
Overall, the practice facilitators embedded themselves in the practice to help physicians and providers identify gaps in care and redesign their practices' workflows to improve clinical outcomes, with the goal being that the physicians can sustain the new skills after the facilitator left. Telligen worked with roughly 90 practices of various sizes in four years.
Conclusion
Together, these two arms of the Health Management Program — care management and practice facilitation — saved SoonerCare almost $140 million over four years, but that's not the only thing the program achieved.
In addition to this substantial savings, the program has had a positive impact on patient and provider satisfaction, according to Mr. Speight. Of the members working with a care manager, 90 percent would recommend the program to a friend. In addition, he shared that more than 85 percent of physicians who worked with a practice facilitator believe it helped them deliver better care. He also added that the program helped achieve improved clinical outcomes and high compliance rates with evidence-based guidelines.
The achievements the program has made for SoonerCare and the Oklahoma Health Care Authority were only possible because of the two-pronged nature of the Telligen program. "Typically [organizations] do one arm or the other, focus on patient behavior and care management or they work with physicians to do quality improvement," says Mr. Speight. "Doing one without the other is not effective. You have to address both to get the results we've been able to achieve."
Dr. Herndon also added, "We expected to see cost savings, but I have to admit we had no idea how much it would be. We're very pleased to see that the savings was this great. However, the most satisfying result is to see that the model we designed and partnered with Telligen to implement has literally changed the way health management is done in Medicaid at a national level."
The Oklahoma Health Care Authority and Telligen are now working under a new five-year contract that took effect July 1.