Start: February 2005

End: August 2007

Funder: Kaiser Permanente, with additional support from the Robert Wood Johnson Foundation


Adults with chronic conditions make up approximately 40 percent of the Medicaid population. Yet costs for their care account for more than 80 percent of Medicaid’s expenditures.

More importantly, these patients often do not get the appropriate care they need. While a limited number of innovative approaches for caring for this population are being piloted, the majority of these Medicaid patients’ health care remains relatively unmanaged in the current environment.

The Medicaid Value Program: Health Supports for Consumers with Chronic Conditions brought together 10 teams to test innovative models of care delivery for Medicaid recipients with multiple chronic conditions. Throughout the two-year initiative, participating teams received ongoing technical assistance to improve how care for consumers with multiple chronic conditions is delivered, integrated, measured and/or financed.

An independent evaluation of the program offers promising lessons for improving care for Medicaid’s highest-risk and highest-cost beneficiaries. The evaluation, along with case studies and logic models details the interventions, are available for download. Below are links to brief overviews of pilot projects:

  • CareOregon
  • Comprehensive NeuroScience, Inc.
  • District of Columbia Department of Health, Medical Assistance Administration
  • Johns Hopkins Healthcare LLC
  • Managed Health Services, Inc.
  • McKesson Health Solutions
  • Memorial Healthcare System
  • Partnership HealthPlan of California
  • University of California at San Diego
  • Washington State Department of Social and Health Services

CareOregon
The CareOregon Complex Care Support Program
CareOregon, a Portland-based health plan, expanded and redefined a complex care management program targeted toward its highest risk and most complex members, including members dually eligible for both Medicaid and Medicare. Typically, these patients have chronic medical conditions that are complicated by mental health issues, such as depression, bipolar disorder, or schizophrenia, or social issues such as homelessness, addictions, or lack of adequate social supports. The goals of the program were to respond to members’ immediate needs, reduce emergency room visits (particularly inappropriate or avoidable visits) and hospitalizations, and ultimately, reduce “modifiable risks” to improve health status and lower utilization costs. Partners in this project included Multnomah County Health Department clinics, Legacy Health System, Oregon Health and Science University, and the Oregon Medical Assistance Program.


Comprehensive NeuroScience, Inc.
Medical Risk Management in Missouri: Improving the Quality of Care for Persons with Schizophrenia and Co-occurring Medical Conditions
Comprehensive NeuroScience, Inc., a clinical research company, partnered with the Missouri Department of Mental Health and Division of Medical Services to implement a Medical Risk Management (MRM) program for consumers with schizophrenia and co-morbidities. The MRM program identified patients at risk of adverse health outcomes and higher utilization of services (medical, behavioral and pharmacy), summarized and communicated recent health care service use to all involved providers, and provided evidence-based recommendations for current care needs. Patients in the MRM program were also assigned a case manager from the Community Mental Health system to assist them in accessing and coordinating both medical and behavioral health care needs.


District of Columbia Department of Health, Medical Assistance Administration
Building a Model of Excellence: Testing Medicaid Waiver Approaches to Case Management and Chronic Care Service Delivery
The District of Columbia Department of Health partnered with Washington Hospital Center, Unity Health Care, and Delmarva to test and validate the clinical and economic outcomes of the Medical House Call Program (MHCP), a Medicaid waiver program that coordinates all home, hospital, and community-based care for elderly consumers. The goal of the MHCP is to assist chronically ill seniors, particularly those with congestive heart failure and co-morbidities, to remain at home. The MHCP uses a multidisciplinary care team approach to visit consumers in their homes (replacing office visits), provide integrated case management, and coordinate all aspects of care. By meeting these needs, the program aims to reduce end-of-life hospitalizations, hospital lengths of stay, emergency room visits, and nursing home placements.


Johns Hopkins HealthCare LLC
Structuring the Integration of Services for Medicaid Recipients with Chronic Illness and Psychiatric and/or Substance Abuse Problems
Johns Hopkins HealthCare, a Baltimore-based health plan, expanded a care management program targeting Medicaid consumers with chronic illness(es) and a co-occurring mental health and/or substance abuse disorder. The intervention employed a team approach to better integrate patients’ medical and mental health care and substance abuse treatment. Through better care integration, reducing barriers to better self-management of medical conditions, and linking patients to community resources as needed, the intervention aimed to reduce inappropriate or avoidable use of services (such as some inpatient admissions and readmissions), and ultimately improve participating patients’ health status while reducing overall utilization costs. Partners in this project included the Maryland Mental Hygiene Administration, and MAPS-MD, the managed care organization administering mental health medical assistance funds.


Managed Health Services, Inc.
Comparative Study of SSI Risk Stratification: Comparing Predictive Modeling Data with Health Risk Assessment
Managed Health Services (MHS), a health plan in Wisconsin, partnered with Wisconsin Medicaid and APS Healthcare to test two alternative case management identification tools – predictive modeling and health risk assessment screening – for its approximately 6,000 SSI (non dual) consumers with multiple chronic conditions. In addition, while the emphasis was on case management decisions, MHS also studied the relationship between case management and patient hospitalizations and emergency room visits.


McKesson Health Solutions
A Collaborative Group Approach to Consumer Diabetes Education for High Risk Consumers to Support Disease Management Interventions in Oregon and New Hampshire
McKesson Health Solutions, a disease management vendor, partnered with the Office of Medicaid Business and Policy in New Hampshire, the Department of Human Services in Oregon, and the American Diabetes Association to assess the effectiveness of providing diabetes group education to aged, blind and disabled consumers in the New Hampshire and Oregon Medicaid programs. The study compared clinical and financial measures among Medicaid consumers with co-morbidities who participated in group health education in tandem with an existing telephonic and community-based disease management program. Additional partners in this project included Oregon Health Sciences University and Dartmouth-Hitchcock Medical Center.


Memorial Healthcare System
My Valued Partner (MVP) Program
Memorial Healthcare System, a safety net provider in Broward County, Florida, partnered with Florida’s Medicaid Agency to improve care for Medicaid consumers with multiple chronic health conditions though the implementation of the Most Valued Partner (MVP) Program. The MVP program features a Health Navigator as part of the disease management team to organize care and develop a care plan, focusing on the unique psychosocial needs of each patient. The primary objectives of the health navigator include reducing barriers to care, providing linkages to community resources, transitioning patients successfully from inpatient hospitalization to their primary care provider, assisting patients in keeping medical appointments, and promoting patient self-management.


Partnership HealthPlan of California
Reducing Risk of Cardiovascular Complications in Diabetics
Partnership Health Plan of California worked together with seven practice sites, Kaiser Permanente Medical Group, and Medi-Cal to improve screening and care management for diabetics with hypertension, cardiovascular disease, and/or depression. The project implemented concepts from Kaiser Permanente’s Prevent Heart Attacks and Strokes Everyday (PHASE) program including increasing medication use; increasing laboratory testing, monitoring and control of key risk factors; and promoting lifestyle changes. Additional partners included Solano County Mental Health, California Medicaid, Lumetra, and LifeMasters.


University of California at San Diego
Improving Treatment of Depression in a Low-Income and Ethnically Diverse Population of Patients with Diabetes Using the IMPACT Model and Project Dulce
The Department of Family and Preventive Medicine at the University of California, San Diego partnered with the San Diego County Adult and Older Adult Mental Health Services, the Council of Community Clinics, and Medi-Cal to enhance treatment for patients with depression and diabetes. The project expanded Project Dulce, the existing diabetes management program in San Diego County community clinics, to include care management for consumers with diabetes and depression using the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model. While Project Dulce and IMPACT have been individually implemented and independently evaluated in the past (showing positive results), this project provided an opportunity to test and evaluate the combination of the two models.


Washington State Department of Social and Health Services
Washington Medicaid Integration Partnership (WMIP)
The Washington State Department of Social and Health Services worked with Molina Healthcare of Washington to launch the Washington Medicaid Integration Partnership (WMIP) to improve care for SSI consumers with chronic illness and behavioral health needs. The WMIP integrates primary care, mental health, and substance abuse services, long-term care, and disease management for the target population using intensive and ongoing case management services provided by Molina. Building on Washington State research demonstrating that increased access to mental health and chemical dependency treatment can lower medical costs and reduce mortality, this project offered an opportunity to study the effects of care coordination among an SSI population that has a high prevalence of co-morbid chronic conditions.