New England Consortium: Maine
MaineNET/Partnership

Project Overview

MaineNET was originally implemented as a primary care case management model in three counties to improve clinical and administrative coordination of primary, acute and long term care services for elders and adults with disabilities. A "Partnership" component was developed to serve beneficiaries needing long term care services. Under the Partnership, a case manager from the organization responsible for long term care services was located in the physician's office to improve coordination and planning.

The Partnership model of individual care coordination from the physician's office was deemed impractical for replication. Case managers in the regular HCBS program served about 100 beneficiaries. Program enrollment was small due to the difficulty convincing beneficiaries to enroll. Partnership case managers felt overwhelmed with 35 beneficiaries due in part to the additional tasks such handling phone calls normally done by the physician, nurse or office staff, participating in office visits and making more home visits. Although the coordination activities were considered helpful, it was unlikely that the program could be considered financially viable.

After the brief care management implementation, the program transitioned to a population based model for improving outcomes by working with primary care physicians. Five physician groups are participating in the current demonstration project.

Implementation Date: July 2000

Waiver: Not required

Eligible Population:

Adults, age 18 and older, who are eligible as SSI disabled; Adults, age 18 or older, who are eligible for both Medicare and Medicaid and receiving long-term care services or have one of the following targeted diagnoses: congestive heart failure, diabetes, and coronary vascular disease.

Benefit Package: Existing Medicare and Medicaid benefits as supplemented by various waiver programs and state-funded services.

Current Status

The revised program focuses on beneficiaries with diabetes, heart disease and congestive heart failure and offers educational materials to beneficiaries and physicians. The primary goals are:

• Provide physicians with data reports tracking utilization of services central to chronic care management and key quality of care events,
• Establish baseline of chronic care utilization activity and provide benchmark data from within the project as well as national standards of care,
• Encourage and assist physicians to develop interventions to improve outcomes,
• Engage physicians in the development and participation in educational opportunities to address chronic care management.

General Approach

Fifty physicians serving 1,200 elderly and disabled Medicaid beneficiaries in five pilot sites participate in the project. Beneficiaries receive all Medicaid state plan and, if eligible, waiver services. The MaineNET program manager from the University of Southern Maine, Edmund S. Muskie School of Public Service meets regularly with the physician leader or administrator of each participating group. Physicians receive reports based on Medicaid and Medicare claims data and meet periodically with the Program Manager (a health educator with quality improvement, patient education and physician practice management experience) to review data and discuss interventions. A pharmacy consultant is also available to provide additional academic detailing services to the pilot sites.

Aggregate data is presented for all patients of the participating group and includes people receiving prescriptions from more than three physicians, people with nine or more prescriptions, people with prescriptions that may be inappropriate for people over age 65, and beneficiaries who had not had their prescription filled within the last three months. For example, a quarterly review of pharmacy claims revealed that more that more than 29% of the target population have received more than one or more potentially inappropriate prescriptions. Participating physicians were offered an educational in-service by the project Consulting Pharmacist to review the findings and discuss alternatives to potentially inappropriate medications. Physicians indicated that under the fee for service system, beneficiaries often receive care from multiple sources and primary care physicians receive little if any information about treatments from other providers. The Medicaid data review gives physicians more information about how other professionals are serving the same beneficiaries and offer opportunities for responding to and coordinating care. Physicians are compensated at the contractual rate of $100 per hour for the actual time spent in academic detailing or in-service meetings with the project staff.

Program staff are developing materials that identify and facilitate referrals to available community resources. These efforts include producing a community resources guide and convening a community resources fair for clinical staff. Strategies to address chronic care management are reviewed with the participating physician groups. These include disease registries and other software tools, group visits, self-management education, disease flow charts and tracking tools. The physicians are directed to free or low-cost resources that assist in the coordination of care for individuals with chronic illness. The state Medicaid agency sends educational materials directly to beneficiaries concerning management of their condition.

Next Steps

The program began in early Spring 2002. Utilization data will be tracked to determine the impact. A series of outcome measures have been established that include quality of care indicators, pharmacy utilization and cost measurements. A pre-post analysis will be conducted as well as a critical review of the academic detailing process.

Grant funding for the program ends in July 2003. During the remaining time, options for incorporating the program into the regular Medicaid system will be explored. Development of an on-going physician education program concerning improved prescribing for the elderly is in the works.

Contact Information

Gino Nalli, Project Director
University of Southern Maine, Muskie School of Public Service
96 Falmouth Street
P.O. Box 9300
Portland, Maine 04104-9300

Phone: (207) 780-4237
Fax: (207)780-4953
E-mail address: gnalli@usm.maine.edu
Website: http://www.state.me.us/dhs/beas/mainenet/