Run to Daylight
Care Manager Navigates Complex Care System
By Rebecca Jones
Care manager Nancy Helms (left) advises Michelle Caradine, a participant in the Colorado Regional Integrated Care Collaborative.
Photography by Barry Staver
Michelle Caradine had struggled with multiple health problems for years, but her teeth were causing her the most distress in the fall of 2009. She needed extensive dental work, including a number of extractions.
Medicaid was willing to pay for the extractions but not for the dentures that would replace the pulled teeth. The Littleton woman, 54 and unemployed, had no idea where to turn or what to do.
But Nancy Helms knew. Helms is a care manager at Colorado Access, a nonprofit health plan that provides access to physical and behavioral health care for needy Coloradans. When Caradine became part of a pilot program to provide high-intensity care management to a select group of high-cost Medicaid recipients, Helms was assigned to her.
In general, 20 percent of the population runs up 80 percent of the nation's medical bills. That's true for Medicaid recipients as well. The people assigned to the pilot program, called the Colorado Regional Integrated Care Collaborative (CRICC), had an average of nearly six clinical conditions apiece, had seen multiple doctors and had been prescribed multiple medications. They were likely to run up medical bills more than three times as high as the average Medicaid recipient. Yet half of them didn't have a primary care provider. Four years ago, CRICC set out to determine if intensive health guidance and low-cost preventive and maintenance care could stave off future medical problems and expenses.
For Caradine, Helms approached a foundation that provides dental assistance for those in need. It agreed to cover most of the costs for Caradine's dental surgery and dentures. With her dental needs finally met, many of Caradine's other health issues also improved.
"Nancy got the ball rolling," says Caradine. "Once she got it rolling, she never stopped. She came to my house on a couple of occasions to get the paperwork done, to make sure all the t's were crossed and i's were dotted. If it weren't for Nancy, I don't think I ever would have gotten my dentures."
CRICC's final evaluation won't be available for another year, says Gretchen McGinnis, vice president of Public Policy and Performance Improvement for Colorado Access. But preliminary figures indicate significant increases in the number of Medicaid recipients who saw primary care providers, and decreases in the number winding up in the emergency room.
"We didn't see a huge decrease in costs," McGinnis says. "But there was a leveling of costs, and that's significant in a population that normally has ever-escalating costs."
The key to CRICC's success has been developing trusting relationships between clients and their care managers.
"We use a technique called 'motivational interviewing,'" McGinnis says. "We come at it from the perspective that these folks have an enormous set of challenges in their life, and what we think is most important may be way down on their list. We meet them where they are. If we create a helpful relationship, we become their first call when they have a question or are concerned about something."
Care managers frequently sit in when their clients visit their health care providers, documenting what happens and helping them to better understand what they need to do to get and stay healthy.
CRICC has since morphed into a new entity, the state- run Accountable Care Collaborative program, which will cover a broader population of people who receive Medicaid. Colorado Access will continue to provide care for Medicaid enrollees in three regions in Colorado. Other organizations will provide care management in the state's four other regions.
The program is evolving, McGinnis says. She hopes it will be given enough time to produce real results. "One criticism we have of the CRICC program is that the kind of reductions and change in health care utilization patterns for this population really is a long-term activity."
In Camden, N.J., for example, a program to provide similar services for people with histories of multiple health conditions and hospitalizations has seen dramatic results over the course of several years. For just 36 "super-users" of health care enrolled in the program, costs dropped 56 percent and hospital and emergency-room visits fell 40 percent.