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Transforming the Workforce to Provide Better Chronic Care: The Role of Nurse Care Managers in Rhode Island

^{Part 1 in the Transforming the Workforce to Provide Better Chronic Care:

The Role of Registered Nurses series.}^{Click to see the rest of the series.}
Chronic illnesses are responsible for more than three-quarters of health care spending and 7 out of 10 deaths in the United States—and nearly half of all Americans have at least one chronic illness—according to the Centers for Disease Control and Prevention.
To improve health outcomes, especially for those with chronic illnesses, and help contain health care costs, commercial and public payers broadly support patient-centered medical homes (PCMHs) for delivery of primary care. The PCMH care model emphasizes quality, comprehensive, coordinated, and patient- and family-centered care.
Many PCMH initiatives have found professional care management to be an effective component of a strategy to improve health outcomes by assisting consumers in accessing the medical, behavioral health, social service, and educational resources they need to best manage their care.
The shift to a PCMH model requires that practice staff improve the way they function individually and collectively as a team; the Rhode Island Chronic Care Sustainability Initiative (CSI-RI) is illustrative of how nurse care managers (NCMs) can function in a PCMH model of care. CSI-RI is a multipayer PCMH program that supports 36 practices with 303 providers, including nurse practitioners and physician assistants who serve over 220,000 Rhode Islanders.

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IMPaCTing Meaningful Improvements in Primary Care Practice

April 9, 2014/in Policy Webinars Cost, Payment, and Delivery Reform, Population Health /by NASHP

Primary care extension programs improve the quality of primary care services by educating providers on new and innovative practices in areas such as preventive medicine, health promotion, and chronic disease management. Section 5405 of the Affordable Care Act authorizes the establishment of a national primary care extension program. To pursue this goal, the Agency for Healthcare Research and Quality (AHRQ) established the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative as a pilot to build on states with strong existing extension programs to serve as a potential model for a national extension program.
This webinar will feature a high-level overview from each of the four lead IMPaCT states (New Mexico, North Carolina, Oklahoma and Pennsylvania) that highlights key components of their extension models. Following the overviews, a facilitated discussion with state officials from these states will illuminate the role of, and implications for, state agencies in this work. Following the discussion, participants will have the opportunity to ask questions of the speakers.
Speakers:

Bob Mcnellis, Senior Advisor for Primary Care, Agency for Healthcare Research and Quality (AHRQ)
Darren DeWalt, MD, MPH, Associate Professor of Medicine, Division of General Internal Medicine, University of North Carolina – Chapel Hill
Robert Gabbay, MD, PHD, Chief Medical Officer and Senior Vice President, Joslin Diabetes Center
Art Kaufman, MD, Vice Chancellor for Community Health; Distinguished Professor, Family & Community Medicine, University of New Mexico Health Sciences Center
Jim Mold, MD, MPH, Director, Research Division, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center
Chris Collins, MSW, Director, Office of Rural Health and Community Care, North Carolina Department of Health and Human Services
Marcela Myers, MD, Director of Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health
Garth Splinter, Medicaid Director, Oklahoma Health Care Authority

Download Webinar Slides

4.7 MB

Advisors and Technical Faculty

January 14, 2014/in Policy Health Coverage and Access /by NASHP

The Maximizing Enrollment program benefited from the knowledge and thoughtfulness of a number of notable national experts. The program’s core advisors provided initial and ongoing guidance that helped to shape the focus of the program. The national advisory committee (NAC) advised RWJF and NASHP, the national program office, on the program design and participated in the state selection process. These groups not only provided initial guidance to launch the program, but also offered ongoing advice to help the program shift as the national health policy landscape changed with the enactment of the ACA. Members of the technical assistance faculty helped NASHP provide individualized assistance to the states participating in the program. All of these individuals were chosen to participate in the Maximizing Enrollment because of the expertise in their fields, but also for their commitment to the goals of the program. The following list includes members of each group:

National Advisory Committee (NAC) Members

Chair
Dr. Claude Earl Fox, MD, MPH
Professor Emeritus
University of Miami
(Formerly: Executive Director, Florida Public Health Institute, Med Plus)
Rachel Block
Consultant
(Formerly: Executive Director, NY eHealth Collaborative)
Dr. Lisa Dubay, ScM, PhD
Senior Fellow
Urban Institute
(Formerly: Associate Professor, Johns Hopkins University, Bloomberg School of Public Health)
Mary Grealy, JD
President
Healthcare Leadership Council
Thomas Johnson, JD
(Formerly: Executive Director, Medicaid Health Plans of America)
Jane Pearson, RN
(Formerly: Associate Director of Programs, St. Luke’s Health Initiative)
Nicole Ravenell-Edwards, MPA
President and CEO
Southern Institute on Children & Families
Gayle Sandlin, MSW
Consultant
Dr. Robert Valdez, PhD
Executive Director
Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico
Judy Waxman, JD
Vice President, Health and Reproductive Rights
National Women’s Law Center

Core Advisors

Joan Alker
Executive Director
Georgetown Center for Children and Families
Donna Cohen Ross
Director of Enrollment Initiatives & Stakeholder Engagement
Intergovernmental and External Affairs Group
Center for Medicaid and CHIP Services
Center for Medicare and Medicaid Services
(Formerly: Outreach Director, Center on Budget and Policy Priorities)
Stan Dorn
Senior Fellow
Urban Institute
Jocelyn Guyer
Director, Manatt Health Solutions
Manatt, Phelps & Phillips, LLP
(Formerly: Co-Executive Director, Georgetown Center for Children and Families)
Genevieve Kenny
Co-Director, Health Policy Center
Senior Fellow
Urban Institute
Bruce Lesley
President
FirstFocus
Cindy Mann
Deputy Administrator and Director
Center for Medicaid and CHIP Services
Center for Medicare and Medicaid Services
(Formerly: Executive Director, Georgetown Center for Children and Families)
Jennifer Ryan
Director
Intergovernmental and External Affairs Group
Center for Medicaid and CHIP Services
Center for Medicare and Medicaid Services
Christopher Trenholm
Senior Fellow
Mathematica Policy Research
Victoria Wachino
Senior Fellow, Health Care Research
NORC
(Formerly: Director of the Children and Adults Health Programs Group, Centers for Medicare and Medicaid Services)

Technical Assistance Faculty

John Bogasky
Managing Director & Co-Founder
Advancier LLC
Tricia Brooks
Senior Fellow
Georgetown Center for Children and Families
Stan Dorn
Senior Fellow
Urban Institute
Vicki Grant
Partner
Grant & Ravenell Process Management Group
Ian Hill
Senior Fellow
Urban Institute
James Jones
Principal
Sellers Dorsey
Genevieve Kenny
Co-Director, Health Policy Center
Senior Fellow
Urban Institute
Patricia MacTaggart
Professor
George Washington Unversity
Beth Morrow
Director, Health IT Initiatives
The Children’s Partnership
Mike Perry
Partner
PerryUndem Research/Communication
Nicole Ravenell-Edwards
President and CEO
Southern Institute on Children and Families

Cutting the Coding Clutter: How Revamping Denial and Disenrollment Codes Can Keep People Covered and Lower Costs

December 7, 2012/in Policy Reports /by NASHP

By Andy Snyder
December 2012
This blog post was originally published on State Refor(u)m’s State of Implementation Blog
States typically don’t have great information on the reasons why people fall off of Medicaid, or are denied coverage in the first place. Complex, outmoded coding systems can obscure the real story behind an applicant’s denial or disenrollment. A new brief from Maximizing Enrollment authored by Mathematica Policy Research and NASHP suggests a new way to cut through the clutter in order to use denial and disenrollment data more effectively, and potentially save money on administration. As health reform rolls out, updating these systems may also help states better coordinate among Medicaid, CHIP, and health insurance exchanges.
A person’s Medicaid coverage can be denied or end for three main categories of reasons:

Loss or denial of eligibility due to a change in circumstances (for example, if a person has an increase in income, turns 21, moves out of state, or becomes incarcerated);
Failure to pay required premiums; or
Loss or denial of coverage for procedural reasons (because a person does not return paperwork on time or doesn’t submit needed documentation).

This third category—procedural closure—is a major contributor to a “churning” problem, where people lose Medicaid coverage for paperwork reasons, only to return a short time later. Churning off of and onto Medicaid results in added costs and administrative burden for states because enrolling individuals is generally more expensive than renewing them. (Gaps in insurance also can have negative effects on individuals’ health, including increased use of expensive hospital services.) Churn will be even more expensive for states in 2014, when there are more people eligible for public programs and coverage transitions are happening more frequently.
States that can track and understand why people are denied or lose coverage will be in a better position to implement efficient and effective enrollment and renewal systems, and adopt policies that can reduce procedural closures.
When a case is closed and a person’s Medicaid enrollment ends, a computer system or an eligibility worker assigns one or more “reason codes” to explain why. These codesets, however, often are too cluttered to allow for clear analysis. Some states have coding systems that list hundreds of possible reasons that a person’s eligibility for Medicaid can end. Each individual code may have been added for a good reason, but the sheer volume of codes, combined with complicated and confusing definitions, makes it difficult for eligibility staff to apply the codes consistently and reliably.
These complex codesets may result in workers using “catch-all” codes such as “individual no longer meets program requirements,” which can obscure the reasons why people are losing coverage. If a state can’t distinguish cases that were closed due to a change in income from those where a renewal form wasn’t returned, it is letting a valuable data source go to waste.
The new Maximizing Enrollment issue brief recommends a streamlined set of just fourteen codes that classify denials and disenrollments according to the three categories described above: change in circumstances, failure to pay premiums, and procedural reasons.
Since enhanced federal matching funds are available for states to upgrade Medicaid eligibility systems until 2015, and states have to make eligibility system changes to comply with health reform changes, now is a great time for states to design systems that use denial and disenrollment data more effectively. States can use these recommended codes to streamline their systems, make it easier for workers to accurately code cases, and make their data more intelligible, actionable, and comparable with peer states. Most importantly, these codes can help states to get a better handle on the reasons why people who are eligible for Medicaid coverage lose it, and to develop policy solutions to keep eligible individuals enrolled. In short, these codes can help states cut through the clutter and use their data to make smart decisions.
What is your state planning in regard to eligibility systems redesign in the run-up to 2014? Let us know in the eligibility systems discussion.

Issues and Policy Options in Sustaining a Safety Net Infrastructure to Meet the Health Care Needs of Vulnerable Populations

October 10, 2012/in Policy Reports Cost, Payment, and Delivery Reform /by Catherine Hess

As a result of large-scale changes in insurance coverage under the Affordable Care Act (ACA), financing streams for safety net providers will shift. The law provides significant resources for further development of some safety net providers while reducing funding streams for others. The vulnerable populations served by the safety net—poor and underserved communities—may not fundamentally change, but their sources of coverage, and thus, financing for safety net providers who care for these populations, will shift dramatically. To adapt to these changing funding streams, safety net providers will need to engage in new and ongoing payment reform efforts, negotiate their roles with state Medicaid programs and qualified health plans sold through newly established insurance exchanges, and maintain an infrastructure to serve the remaining uninsured. This report, the third in a series that reflects the work of the National Workgroup on integrating a Safety Net into Health Care Reform Implementation, addresses the workforce and financing infrastructure needed to support a sustainable safety net to serve vulnerable populations.

sustaining.sn_.infrastructure.pdf	275.7 KB
sustaining.SN_.infrastructure.pdf	275.7 KB

Toward Meeting the Needs of Vulnerable Populations: Issues for Policymakers’ Consideration in Integrating a Safety Net into Health Care Reform Implementation

January 12, 2012/in Policy Reports /by NASHP and Katharine Witgert

A 2011 Commonwealth Fund poll found that 98 percent of responding national health care opinion leaders believe that traditional safety net providers will still fulfill critical roles after implementation of the ACA. With the support of The Commonwealth Fund, NASHP formed the National Workgroup on Integrating a Safety Net into Health Care Reform Implementation to inform national and state policy development in addressing the roles of safety net providers in implementation of the ACA. This brief describes 10 overarching issues that the National Workgroup identified as ones that policymakers concerned with the safety net will need to consider in order to achieve health care reform goals, particularly for vulnerable populations.

safety.net_.hcr_.pdf

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Reimbursing Medical Providers for Preventive Oral Health Services: State Policy Options

February 11, 2010/in Policy Reports Health Coverage and Access /by NASHP Staff

Tooth decay, while highly preventable, is the most common chronic disease among children, and it disproportionately affects children from families with low incomes. Many state Medicaid agencies are working to increase children’s access to preventive oral health services by reimbursing primary care medical providers for fluoride varnish application, an oral examination or screening, and/or caregiver education about establishing good oral health habits. This report is intended to help states considering adopting similar policies; it draws from the experiences of Iowa, Minnesota, North Carolina, Utah and Washington to describe some of the major elements of policy design and implementation, as well as lessons learned associated with medical provider reimbursement.

Pew Oral Health

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Engaging Primary Care Medical Providers in Children’s Oral Health

June 24, 2009/in Policy Reports /by NASHP Staff

Access to dental care in the U.S. is a severe problem for young children, underscored by the fact that only a quarter of all children under six had a dental visit in 2004. In an effort to address these access issues, many states have begun reimbursing medical providers for delivering basic oral health services to children. This issue brief provides an update to the 2008 State Health Policy Monitor, The Role of Physicians in Children’s Oral Health, which highlighted state efforts to increase access to preventive dental care through the use of medical providers. Currently, 34 state Medicaid programs reimburse primary care providers for performing preventive oral health care services on children, including nine new state programs since last year’s study. These preventive oral health care services include the application of fluoride varnish, anticipatory guidance/caregiver education, risk assessment, and an oral examination/screening. The use of primary care providers as a first line of defense in children’s oral health provides an opportunity to facilitate a more cohesive working relationship between the dental and medical communities.
This project is supported by The Pew Center on the States’ Advancing Children’s Dental Health Initiative.

Primary Care Providers & Children’s Oral Health

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Help Wanted: A Policymaker’s Guide to new Dental Providers Report

June 4, 2009/in Policy Reports /by Mary Takach

Access to dental care is an increasingly serious problem for many people in the United States, particularly for children. There is a shortage of private dentists and a limited availability of affordable, or government-supported dental care. This is further compounded by the small number of private dentists willing to participate in public health insurance programs, or treat young children and other underserved populations, especially in rural areas.
As a result, many states are exploring the option of adding a new type of dental provider to the existing dental health team, similar to a nurse practitioner or physician assistant. The policy brief and report “Help Wanted: A Policymaker’s Guide to New Dental Providers,” explains the options and gives states the tools they need as they consider new and creative ways to deliver quality dental services to people who need them.
The Pew Center on the States and the National Academy for State Health Policy (NASHP), with support from the W.K. Kellogg Foundation, conducted a comprehensive literature review and interviews with leading experts in several states to learn about existing proposals for new dental providers. The report and brief explore three provider types-dental therapists, community dental health coordinators and advanced dental hygiene practitioners – along with steps that state policy makers can consider to develop these new providers in their states.

New Dental Providers Report

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Making Medicaid Work for the 21st Century: State Options to Control Costs

April 17, 2009/in Policy Reports /by NASHP

One of a series of issue briefs designed to share with federal and state policymakers, as well as other stakeholders, the issues and options raised by the Making Medicaid Work for the 21st Century workgroup. This brief discusses state options to control costs.

mmw_costcontrol.pdf

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