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Washington Chronic Care Management Program

jessievenegas Jessie Venegas — 12/01/2009

Foresight Links Corporation

With the discontinuation of the Medicaid Disease Management pilot in 2006, the state sought a new strategy to progress from a disease-specific focus to a more holistic approach for its most complex and costly populations. In particular, state officials felt it was critical to target beneficiaries who would benefit most from care management techniques to prevent the disease progression that results in increasingly expensive care and poor quality of life. As a result, the state developed the Chronic Care Management Program (CCMP). This program, launched in January 2007, pairs the techniques refined in the state's Disease Management program with a predictive modeling tool that identifies beneficiaries at highest risk for service use. CCMP provides case management, education and support, as well as assistance accessing health resources, for fee-for-service ABD beneficiaries who are identified as high risk. It also provides more traditional telephonic disease management and care management services. This two-pronged approach allows the state to test different models of care to see what works best and continuously improve program quality. The following care management activities are offered to participating beneficiaries: * Screen/assess risk factors such as health status, self-management skills, adherence to treatment plan and prescribed medications, and individual needs such as limited English proficiency and health literacy; * Develop a personalized care plan that includes a focus on self-management skills; * Link beneficiaries to a medical home; and * Refer beneficiaries to medical, mental health, chemical dependency service providers, and other social services as needed To ensure continuous quality improvement, the state evaluates CCMP using a randomized controlled design to achieve more rigorous comparisons of quality and cost-savings. Condiciones crónicas que considera la práctica:

Fragility, pluripathology/polipathology and/or complex chronic diseases







Practices Map



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