Understanding Medicaid Case
Management for Child Health
Presenter: Kay Johnson
Co-authors: Sara Rosenbaum, Anne
Markus, Emily Jones
Academy Health / Child Health Services Pre-Conference
Chicago, IL
June, 2009
This work supported by a grant from The Commonwealth Fund to the George
Washington University, School of Public Health and Health Services,
Department of Health Policy.
Rosenbaum, Johnson, Jones. & Markus.
Medicaid and Case Management to Promote
Healthy Child Development.
The Commonwealth Fund, 2009
Johnson & Rosenthal. Improving Care
Coordination, Case Management and
Linkages to Service for Young Children.
The Commonwealth Fund/NASHP, 2009
Johnson and Rosenbaum. Medicaid Case
Management in a Maternal and Child Health
Context: An Overview of Policy and Practice.
Prepared for MCHB-HRSA. March 2008.
Overview of Presentation
1. Definitions and framework
2. Highlights of literature review
3. Examples of case management
strategies used by states
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
A New
Framework
Defining Case Management
 Terms
“care coordination” and “case
management” both used, often interchangeably
Here identified as CC/CM
 Medicaid finances only “case management”

 Promoting access to services for children
 For those with health in “normal range,” reducing
access barriers related to language, health literacy,
culture, geographic access, etc.
 For children with special health care needs
(CSHCN), additional help navigating health care
system and communicating with providers.
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Overall Functions & Purposes

Enhancing access


Managing utilization



Reduce barriers related to language, geographic
access, low health literacy, culture
Augment or limit use of services
Facilitate access to needed care and/or assure only
necessary services are used
Assisting those with complex health needs

Assure implementation of care plans involving
multiple providers, appropriate utilization
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Defining CC/CM in Insurance Terms
Four considerations:
1. Function and purpose of CC/CM
2. Health care vs. administrative service
3. Qualifications and activities of case
manager
4. Payment methods
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Payment for Case Management
 What
is being purchased? Is the service:
Stand-alone
 Integral to health care (e.g. medical home,
disease management)
 Component of administration in capitated plan

 How
are payments to be made?
Paid separately FFS
 Bundled (e.g., hospital rates, newborn
screening)
 Capitated fee (MCO, PCCM)
 Salary to staff

Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Tiers of Case Management
More complex
health conditions
More experienced
and knowledgeable
case manager
Intensive
review &
management
Case
management for
complex, special
health needs
Less complex
health conditions
Support & navigation
to reduce barriers
Less specialized
medical knowledge
needed by case
manager
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Tiers of CC/CM

1st tier:



2nd tier:



Support to overcome barriers
Staff skills in navigation, communication
Assist those with complex, special health care needs
Staff skills in navigation, communication, medical
knowledge
3rd tier:


Assist with access and manage utilization
Staff skills all of above, plus clinical knowledge sufficient
to made certain determinations of medical necessity
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Highlights of the
Literature Review
Reducing barriers to preventive care (A)
 Evaluation
of CC/CM home visit intervention
to improve use of well child visits.[1]

RESULTS: Slightly more likely to have visits.
 Systems
approach including CC/CM and
community change. [2]

RESULTS: 57% intervention vs. 37% historical control
cases.
[1] Schuster et al. 1998. Utilization of well-child care services for African-American infants in a
low-income community: results of a randomized, controlled case management/home visitation
intervention. Pediatrics. 101:999-1005.
[2] Margolis et al. From concept to application: the impact of a community-wide intervention to
improve the
delivery
of preventive
services
children.toPediatrics.
2001;108(3):E42
. June 2009
Johnson,
Rosenbaum,
Markus, Jones:
Caseto
Management
Promote Healthy
Child Development.
Reducing barriers to preventive care (B)
 RCT

both office- & home-based CC/CM [1]
RESULTS: Intervention group more likely to have visit,
identify a primary care source, and recall of patient
education materials.
 Case/control
study of systems approach
including CC/CM and community change. [2]

RESULTS: Appropriate utilization 57% intervention vs. 37%
historical control cases.
[1] Margolis et al. 1996. Linking clinical and public health approaches to improve access to health care for
socially disadvantaged mothers and children. A feasibility study. Arch Pediatr Adolesc Med. 150:815-21.
[2] Margolis et al. 2001. From concept to application: the impact of a community-wide intervention to improve
the delivery Johnson,
of preventive
services
to children.
Pediatrics.
108(3):E42.
Rosenbaum,
Markus,
Jones: Case
Management
to Promote Healthy Child Development. June 2009
Maternity and Infant CC/CM

Prenatal CC/CM in NC



Maternal and infant CC/CM


RESULT: Improved use of prenatal care & outcomes.
Cost-effective.[1]
RESULT: Improved preventive care utilization for
infants.[2]
Systematic review concluded that Medicaid should
provide intensive CC/CM prenatal and postpartum
to high risk women.[3]
[1] Buescher et al. 1991. “An Evaluation of the Impact of Maternity Care Coordination on Medicaid Birth
Outcomes in North Carolina.” AJPH 8: 1625-1629; Buescher and Ward. 1992. “A Comparison of Low Birth
Weight Among Medicaid Patients of Public Health Departments and Other Providers of Prenatal Care in North
Carolina and Kentucky.” Pub Health Rep 107: 54-59; Buescher et al. 1987. “Source of Prenatal and Infant
Birth Weight: the Case of a North Carolina County.” AJOG 156: 204-210.
[2] Erkel et al. 2007. Case Management and Preventive Services Among Infants from Low-Income Families.
Public Health Nurs. 11:352-360.
[3] Meyer J and Smith B. 2008. Chronic Disease Management: Evidence of Predictable Savings. Health
Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
ManagementJohnson,
Associates.
CC/CM through PCCM
 PCCM
pediatric patients with CC/CM
RESULT: Improved use of primary care
 Reduced hospitalization, both avoidable and
emergent.[1]

[1] Gadomski, A; Jenkins, P and M Nichols. 1998. “Impact of a Medicaid Primary Care
Provider and Preventive Care on Pediatric Hospitalization.” Pediatrics 101(3): e1-e11.
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
CC/CM and the Medical Home
 CC/CM
is a core function in a medical home
as defined by:
NCQA program to assess function - the
Physician Practice Connections® – PatientCentered Medical Home™ (PPC®-PCMHTM)[1]
 American Academy of Pediatrics and MCHB
 Medical home model for CSHCN [2] [3]

[1] National Committee for Quality Assurance (NCQA).
http://www.ncqa.org/tabid/631/Default.aspx
[2] Cooley and McAllister. 2004. “Building Medical Homes: Improvement Strategies in Primary Care
for Children with Special Health Care Needs.” Pediatrics 113(5): 1499-1506.
[3] Antonelli et al. 2009. Developing Care Coordination as a Critical Component of a High
Performance
Pediatric Health
Care
System.
New York, NY:
The Commonwealth
Fund.
Johnson, Rosenbaum,
Markus,
Jones:
Case Management
to Promote
Healthy Child Development.
June 2009
Practice CC/CM across levels of need

In-depth study of 20 general pediatric practices [1]
CC/CM for patients of all complexity levels



RESULTS: Regardless of health needs, those with family
social stress were 24% of patients served but used 41% of
CC/CM minutes.
With family stress + CSHCN used 21% of CC/CM
minutes.
CONCLUSION: Family social stressors is at least as
important as the presence of a special health care need in
assessing the need for CC/CM services.
1 Antonelli et al. 2008. Care coordination for children and youth with special health care
needs: a descriptive, multisite study of activities, personnel costs, and outcomes.
Johnson,
Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Pediatrics.
122(1):e209-16.
Percent of CSHCN 0-17
Unmet Need for Care Coordination
Among CSHCN 17 and Under, 2005
90
80
70
60
50
40
30
20
10
0
Need for Care
Coordination
Unmet Need
for Care
Coordination
0-99%
100-199%
200-399%
400%+
Percent of federal poverty level
Source: National Survey of Children with Special Health Care Needs
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Meta/systematic analyses: CSHCN

Meta-analysis of cc/cm for CSHCN noted a
paucity of studies, but most of the 7 studies
identified indicate modest but positive effects. [1]

Review of studies on psychosocial interventions
for CSHCN found modest positive effects [2]

Children and their families were better able to cope
with social and psychological aspects of their health
condition.
1 Wise, Huffman and Brat 2007. 2007. A Critical Analysis of Care Coordination Strategies for Children with
Special Health Care Needs. AHRQ.
2 Bauman et al. 1997. “A Review of Psychosocial Interventions for Children with Chronic Health Conditions.”
Pediatrics 100:
244-251.
Johnson,
Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
RCTs on Case Management & CSHCN
 “Family
support” through pediatric clinics 1
RESULTS: Decreased likelihood of mental
health problems
 Improved the functional adjustment of children.

 Case
management in specialty clinics 2
RESULTS: Improved psychosocial functioning
of CSHCN
 Mixed results for some outcomes.

1 Chernoff et al. 2002. A Randomized, Controlled Trial of a Community-Based Support Program for Families of
Children with Chronic Illness: Pediatric Outcomes. Archives of Pediatric and Adolescent Medicine 156: 533539.
2 Pless et al. 1994. A Randomized Trial of a Nursing Intervention to Promote the Adjustment of Children with
Chronic Physical
Disorders.
Pediatrics
Johnson,
Rosenbaum,
Markus,94(1):
Jones:70-75.
Case Management to Promote Healthy Child Development. June 2009
CC/CM in Medical Home for CSHCN

Model Intervention Studies (pediatric NP case manager, parent
consultants, individualized health plan, and CME for health professionals)

Medical home intervention in six private pediatric practices [1]




RESULTS: Increased parent satisfaction with primary care;
Improved child health outcomes; and
Reduced disease burden at annual cost of only $400 per patient.
Same model in university-affiliated primary care [2]



RESULTS: Positive results—reduced absence from school and
work, decreased caregiver strain, and fewer ambulatory care visits;
Mixed results for parental satisfaction; and
No decrease in hospitalizations.
[1] Palfrey et al. 2004. Pediatric Alliance for Coordinated Care. The Pediatric Alliance for Coordinated Care:
evaluation of a medical home model. Pediatrics 113(5 Suppl):1507-16
[2] Farmer et al. 2005. Comprehensive Primary Care for Children With Special Health Care Needs in Rural
Johnson,116(3):
Rosenbaum,
Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Areas.” Pediatrics
649-656.
Evaluation Case Management CSHCN

Hospital-based CC/CM for CSHCN with inpatient
and outpatient elements 1



RESULTS: Reduced length of stay and hospital charges
fell for the treatment group.
Estimated savings of $200,000 over the three year
duration of the experiment.
A hospital-based, ambulatory CC/CM for CSHCN 2


RESULTS: Reduced admissions, length of stay, and
inpatient charges.
Estimated savings of $77.7 million in inpatient care over
a ten-year period.
1 Criscione et al. 1995. “An Evaluation of Care Coordination in Controlling Inpatient Hospital Utilization of
People with Developmental Disabilities.” Mental Retardation 33(6): 364-373.
2 Liptak et al. 1998. “Effects of Providing Comprehensive Ambulatory Services to Children with Chronic
Johnson, Rosenbaum,
Jones: CaseMedicine
Management
Promote Healthy Child Development. June 2009
Conditions.” Archives
of PediatricMarkus,
and Adolescent
153:to1003-1008.
CC/CM for
Children
Strategies Currently in
Use by States through
Medicaid and Title V
EPSDT CC/CM
 EPSDT
care coordinators/case managers
Working at the local level to support families
and providers
 Used by several states with Medicaid &/or
Title V financing (IA, CO, ME)
 Typically nurses or social workers
 Providers generally work for local health
departments

Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
CC/CM for CSHCN
 Dedicated
CC/CM for children with special
health care needs
Used by virtually all states with Medicaid
&/or Title V financing
 May be in primary or specialty care or
community-based
 Provider may be from:

 Managed
Care Organization (MCO)
 Pediatric practice
 Parent-to-Parent Support organization
 State or local health department
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
CC/CM for Maternal & Infant Care
 Focused
on pregnancy and postpartum
(interconception) care women and infants
Used in many states with Medicaid and/or Title
V financing (e.g., NC, KY, WV, MI, IL)
 Also use in federally funded Healthy Start sites
 Provider may be from:

 State
or local health department
 Visiting Nurse Association
 Freestanding home visiting program
 Managed Care Organization (MCO)
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Primary Care Case Management
 Primary
care case management (PCCM) to
support the medical home
Used by some State Medicaid agencies for
pediatric care (e.g., IL, CT, TX)
 Provider accepts responsibility for care
coordination and overall management of
services
 Type of managed care, generally capitated
fee payment
 New models emerging with emphasis on the
medical home

Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
Piloting a New Tool on CC/CM
PURPOSES:
1. Assessing flow of the child health system
2. Understanding how care coordination and
case management “fit into the picture”
3. Working in collaboration with Medicaid,
Title V MCH, and other partners to better
support families and providers
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009
©Johnson Group, 2008. For MCHB-HRSA
Johnson, Rosenbaum, Markus, Jones: Case Management to Promote Healthy Child Development. June 2009