Improving Utilization of Tools to Care for Complex Patients

Creating effective interventions to care for complex populations and making them available is only half the battle. That was the lesson gleaned from a workshop session at The National Center for Complex Health and Social Needs’ Putting Care at the Center conference, held December 7-9 in Philadelphia, Pennsylvania.

Representatives from Wisconsin and Michigan state government agencies, as well as practicing clinicians, made up a panel of speakers who discussed sustaining effective interventions for high-cost, high-need patients. The 2 states have been participating in the National Governors Association (NGA)’s Complex Care Policy Academy.

What Rebecca McAtee, director of the Bureau of Eligibility, Policy, and Systems at Wisconsin Department of Health Services, has learned through her 4 years of working with NGA, is that persistence pays off.

“Our initiative has really taken a twisty, turny road,” she said.

In the first year of the program, the first phase was identifying the population of complex patients and the geographic location to focus in on. The second phase was engaging stakeholders. While the first phase proved successful—the data was validated and they were able to identify the appropriate population—the second phase proved harder than anticipated.

“When we initially went in we thought we would be working with providers and they would be super engaged and everyone would be ready to jump into the bandwagon,” McAtee said. “That was not the case.”

Part of the issue was the risk providers were being asked to take on. On the other hand, the state’s health maintenance organizations (HMOs) were engaged and willing to take on the risk. But even this proved a challenge: they had to instill trust in HMOs among both the public and providers.

Michigan took a slightly different approach and focused on housing. The goal was to get the population past the housing crisis and get them into housing with the use of subsidies, which, in turn, would reduce the utilization of emergency services.

According to Kelly Rose, of the Michigan State Housing Development Authority, the challenge became: “How do we show that return on investment?” The benefits of this program would be shown years, maybe decades later.

In the state of Michigan, 4% of the population are considered super utilizers; that is, they have 20 or more emergency department inpatient visits a year and they account for 40% to 50% of the healthcare spend. And the state government is paying attention now, said Lynda Zeller, director of behavioral health and development disabilities at the Michigan Department of Health and Human Services (MDHHS).

“The governors are paying attention,” she said. “The housing people are paying attention. Medicaid is finally paying attention to housing, for once.”

The state housing agency worked closely with the MDHHS because the population they were trying to serve had different needs from both of their departments.

It’s common sense, Rose said, “if someone is living in homelessness, they are not going to be keeping up with medications, they are not going to be keeping up with their health.”

Unfortunately, this understanding had not led to utilization. In Michigan, the behavioral health system has been allowed to pay for tenancy support for approximately 15 years, but only a handful of communities use it.

In addition, on the physical care side, the state has a lot of HMOs, and they have the ability to use additional unique services in lieu of the regular state Medicaid plan as long as they prove they are providing better quality care at lower cost. And yet, none of the state’s HMOs are paying for tenancy supports, Zeller said.

“And how many HMOs do we have that are paying for tenancy supports in lieu of it today? Zero,” Zeller said.

So the state is going to run pilot programs to choose 4 communities where the state knows there are super utilizers, and help the communities better understand what they are not utilizing.

Showing that the programs work and getting them used is important and necessary in order to make care management sustainable, McAtee said.

“And it’s really in the best interest of the people in our state,” she said.