Program holds blueprint to Medicaid’s future
February 1, 1997 4 minutes read
Program holds blueprint to Medicaid’s future
Education is key in managed care for the poor
Education managers will have their hands full if their states turn Medicaid programs into managed care operations, says one expert who has dealt with such a change for the past two years.
"It’s a lot of work," says Charleace Warren, RN, vice president of professional services for Homecare Health Services of McKenzie, TN.
Tennessee changed its Medicaid program in 1994 to what is essentially a managed care program that contracts with private insurance companies.
"The managed care organizations didn’t send out instructions or manuals, and then comes January 1 [1994], and we had to start precertifying for Blue Cross, which was the primary MCO that our Medicaid patients chose," Warren says.
Health care providers with Homecare Health Services, a large home care agency that serves 24 counties in middle and western Tennessee, found that they’d have to educate themselves in order to make the program a success.
The program called TennCare covers acute care, hospital stays, home care, physicians, outpatient services, mental health, pharmacy — everything except nursing home care.
Some changes were eye openers, Warren recalls. The agency was accustomed to treating new insulin-dependent diabetics with two months of visits, three times a week, perhaps even daily to start. Under Blue Cross’ TennCare program, the home care agency would have to teach a new diabetic everything he or she needed to know in only three visits.
"We learned to do a lot of assessment and teaching over the telephone," Warren says. "And we learned in some situations that if the patients were very elderly or their educational level was such that they couldn’t learn all this in three visits then they would have to be recertified as to why they needed more than three visits."
Homecare Health Services providers had to write a lot of appeals, especially when it concerned patients’ safety. They worked at convincing the MCOs and case managers to look at their appeals; they sent in a patient’s documentation multiple times.
"Under TennCare you have to precertify very often," Warren explains.
She uses an example of a new insulin-dependent diabetic, who also needs wound care. When the agency sends in its precertification for visits, the nurses include the diabetes, education, and wound care. "You ask for daily times five for one week, and then three times a week for one week, and you think eight skilled nursing visits for this patient would be sufficient."
But the MCO sends the forms back, saying the work can be done in only three visits.
"So you do the three visits, and then you send it back in and ask for more visits, and each time you have to do a precertification," Warren says. "If the patient falls in the middle of the night, or if you have to do another visit, within 24 hours you have to do a precertification to explain why that one visit was necessary."
Warren advises education managers to keep it simple: "There are a lot of acronyms and terms to learn, and I tried to make it very simple."
She gave staff handouts and questions and answer sheets. Wherever possible, she threw in some jokes, and she explained how and why health care is changing. "I explained what was going on in Tennessee and why home health services would grow under managed care or should grow because that is their job security."
The agency held more inservices, and Warren encouraged nurses to read and advance their skills on their own time.
"Some were real excited about it; they wanted to learn more skills," she recalls. "And then there were others who thought it was ridiculous because they wanted to do things like they always had done under the old rules.
"One woman said that if this was all about money, then she didn’t want anything to do with it."
One key change was to teach nurses how to view the telephone as an important agency tool. An example, Warren relates, might be if the nurse visited a patient in order to teach him or her how to take care of an IV and how to access the port. The nurse could write out instructions for that and ask the patient to do a demonstration while the nurse watched.
"But perhaps the patient had to have a lot of verbal cuing." Warren says this might make the nurse uncomfortable with leaving the patient alone the next time, so she would suggest the nurse call the patient at the time the patient was supposed to do the procedure.
"That way the nurse could find out if the patient was comfortable doing the procedure and make sure the patient was successful."
In retrospect, Warren believes her agency did a good job of adapting to the changes under TennCare. But she sees this as only the beginning because 98% of the agency’s business comes from Medicare, which also might change to managed care in the near future.
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