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jessievenegas Jessie Venegas — 11/01/2009

Primary Care, Department of Health

This is an enhanced primary care case management (EPCCM) and disease management program that started in 2005. Pay-for-participation payments are made in addition to Medicaid fees paid for covered professional services. Physicians receive payments for: * Reviewing and partnering in the ACCESS Plus program. * Contacting newly eligible high-risk patients to encourage them to enroll in the program. * Furnishing contact information for selected patients. * Completing the Chronic Care Feedback Form that care coordination nurses use to help them monitor and coach high-risk patients more effectively. * Implementing clinical interventions for year one, based on self-reported data by high-risk patients. * Implementing clinical interventions for year two, based on claims data for both high-risk and low-risk patients. * Implementing clinical interventions for year three (measures yet to be selected). In November 2007, Pennsylvania transitioned its program to reward providers for improvements in clinical outcomes. Three care management units operate for the ACCESS Plus population: Primary Care Case Management, Disease Management, and Intensive Case Management. All three units work together to refer patients to respective units that can better meet their needs: * Primary Care Case Management. This unit, operated by Pennsylvania's vendor, provides care or services beyond what is typically offered to PCCM members. Services might include prevention, care coordination, and support for high-risk pregnancies. * Disease Management. Operated by Pennsylvania's vendor, this unit includes a field staff of community-based nurses and workers. The community-based nurses help deliver disease management services to program members. Interventions can be telephonic or in-person if staff are unable to reach the member by telephone. Nurses encourage members to visit their primary care provider, teach members to recognize signs of disease process, increase members' self-management skills, coordinate with the provider's plan of care, and promote a healthy lifestyle. Community-based workers locate the member, explain services and benefits, and help locate basic community resources. Pennsylvania's vendor employs a proprietary risk stratification methodology with three tiers: 1. Level One. Educational mailings, nurse call line, audio health libraries. (The patient receives a call from a nurse care manager at weeks six and 26.) 2. Level Two. All Level One services plus more frequent calls from a nurse care manager. (The patient might be referred to PCCM, whereby the patient's provider is notified that he or she is receiving disease management.) 3. Level Three. All Level One and Level Two interventions plus in-person visits and a more intensive call schedule. 4. Intensive Case Management. Operated by State staff, this unit provides services to high-risk members with a range of conditions. The majority of case management is telephonic; in-home visits are conducted on a case-by-case basis.

Fragility, pluripathology/polipathology and/or complex chronic diseases, All

Goals Prevention:
Funding for detection programs , Promotes adecuate understanding levels on the community about the importance of prevention
Goals Detection:
Promotes early intervention through primary health care measures , Provides registries and patients contact systems , Shows new evidence on the importance of early detection, including guidelines of effective practices , Advances public education on the importance of early detection
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Promotes the appropriate use of medicines , Emphasizes the care of pluri-pathological and fragile patients
Goals self-management:
Refocuses the health system to support self-management , Promotes patient involvement in planning services , Improving support services with an emphasis on peer support, the disabled and carers , Allows home care , Allows remote support to patients and their carers from health professionals

None

Progress

UNITED STATES OF AMERICA

Pennsylvania

Pennsylvania

Pittsburgh

McKnight Road Suite 300 Pittsburgh, PA 15237
Practices Map
 

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