Impact Feature Issue on Enhancing Quality and Coordination of Health Care for Persons with Chronic Illness and/or Disabilities

The Wisconsin Partnership Program (Partnership) is an integrated health and long-term managed care program. Partnership provides services for both people with disabilities and older adults, and has been operational in six counties in Wisconsin since 1999. Partnership combines all health and long-term care services offered under Medicare, Medicaid, and the Medicaid Home and Community-Based Waiver programs. As such, it provides a very comprehensive benefit package. Two capitation payments, Medicare and Medicaid, are paid to one of four community-based organizations that coordinate and manage all aspects of care for program enrollees.

Partnership Operation

The term “partnership” is indicative of the numerous collaborative relationships that it took to develop the program and that it takes to administer and achieve optimal outcomes for consumers. Partnerships exist between:

• The Center for Medicare and Medicaid Services (CMS) and the Wisconsin Department of Health and Family Services (DHFS).
• DHFS and the four Partnership organizations – Community Health Partnership, Eldercare Health Plan, Community Living Alliance, and Community Care Organization.
• CMS and the Partnership organizations.
• The Partnership organizations and their members.
• Various segments of state and county government.
• Partnership organizations, members, and subcontracted providers.

The successful operation of Partnership is dependent on maintaining collegial and sometimes contentious relationships in the face of competing regulations and priorities. The program would not operate or deliver successful outcomes for members without these collaborative partnerships.

Partnership operates under 1115 Medicaid demonstration authority and 402/222 Medicare payment waiver. To be eligible for Partnership, a potential enrollee must be Medicaid eligible and meet nursing home level of care criteria. Partnership members enter the program with an average of 17 diagnoses and take more than an average of 13 prescription medications. As of October 1, 2004, there were 1,723 people enrolled in Partnership – 1,330 older adults and 393 people with physical disabilities. Eighty-three percent of those enrolled live in their own homes with various levels of support, about 10% live in assisted-living situations, and approximately 7% live in nursing facilities. Roughly 95% of the older adults and 60% of people with disabilities are dual eligible for Medicare and Medicaid.

Care coordination is the heart of the Partnership program. Partnership care coordination is based on a team approach. The team is comprised of the enrollee, the enrollee’s primary care physician, a nurse practitioner, a registered nurse, and a social worker or social service coordinator. Additional staff join the team as called for in the enrollee’s care plan. This team approach has been central to eliminating system and service fragmentation, increasing comprehensive primary care, and providing support for the person in his or her home. It has also been a major factor in minimizing the need for expensive hospital and nursing home care. The outcome has been the provision of comprehensive primary care, prevention services, and community-based long-term care services for Partnership enrollees.

The team conducts assessments, develops plans of care including the provision of health and psychosocial services to meet identified needs, and arranges for the delivery of the services whether they are staff-provided or purchased from subcontractors. Examples of services include primary health care, hospital care, transportation, supportive home care, personal care, and home modifications.

Partnership Medicaid capitation payments are a blend of institutional and home and community-based care costs. Rates are risk-adjusted by age cohort, level of care, and Medicare eligibility (dually eligible/Medicaid eligible only). The risk-adjusted, blended cost is then subject to a managed care efficiency adjustment of 5%. After the end of the year, DHFS staff review the actual enrollment experience of each Partnership organization against the assumptions made in rate development and adjust the capitation payment retroactively.

Within the next three years, rate setting for Partnership will change to a risk-based system. It is likely that this new system will have two components – one to predict health care costs based on diagnostic information, and a second to predict long-term care costs based on limitations in activities of daily living and instrumental activities of daily living. The development of this new method is a collaborative effort between representatives from each of the four Partnership organizations and DHFS.

An Area of Particular Challenge

Partnership has faced a significant challenge in providing services to people with disabilities with a high incidence of mental health and/or alcohol and other drug abuse (AODA) issues in addition to a primary disabling condition. Approximately 53% of all Partnership members have diagnosed or suspected mental health and/or AODA issues. The rate is higher among people with physical disabilities than the elderly; we have not studied why this is the case. Community Living Alliance, one of the Partnership organizations that provides care specifically to people with physical disabilities, estimates that 70% of its membership has issues related to one or both of these conditions. DHFS investigated the impact of mental health and AODA issues on utilization of other services at the Community Living Alliance (Crawford, 2004). The research found that people with an AODA diagnosis spend 65% more days in a hospital than people with no known or suspected AODA diagnosis. This group also experienced nursing home stays at a rate that was 359% greater that those with no AODA diagnosis. Also, the rate of no-shows for scheduled appointments was four times higher than for people without an AODA diagnosis. In a related study, people with both mental health and AODA diagnoses received twice as much inpatient care as those with no mental health or AODA diagnosis (Crawford, 2004). Thus, it is clear that the presence of AODA issues drives much of the cost of serving this subgroup of people with disabilities. Early developers of related long-term care programs, including Partnership, did not anticipate the extent to which AODA problems among enrollees would affect the programs.

Fortunately, Partnership has been in a unique position to provide the care required to address the AODA problems of this population. Because it is a fully integrated health and social services program, Partnership pays for and provides social services, including those needed due to AODA issues. Most other health care insurance programs or providers cover health care, but not social services, or vice versa. To our knowledge, for example, few health care providers and payers have well-developed programs devoted to AODA prevention and intervention. Therefore, as a health care entity, Partnership has been in relatively uncharted territory. It should also be noted that Partnership is unlike typical AODA treatment and/or behavioral health managed care programs. Behavioral health programs do not pay for health or social services needed after clients complete or drop out of AODA treatment. Partnership does.

In addition to implications for costs and general program infrastructure, Partnership also found that the strong presence of AODA issues among enrollees had important implications for staff training. This was true from both a clinical and psychological perspective. Partnership staff reported difficulty in identifying and approaching members with these issues. They questioned the “fairness” of giving more time and resources to those who abused when it was theoretically the individual’s choice to abuse, and experienced frustration when enrollees failed in their attempts at abstinence. Some expressed concern that they may be “enablers” if they tried to rescue abusers from negative consequences.

Because of Partnership’s unique opportunity and challenge in addressing AODA, DHFS applied for and received a grant from the Robert Wood Johnson Foundation to develop training and a training manual for Partnership staff specific to dealing with AODA issues. DHFS contracted with the Center for Excellence in Long-Term Care in the University of Wisconsin-Madison School of Nursing to research AODA literature for best practices and work with Partnership staff to address their concerns. When enough post-training data are available, a follow-up study will be conducted to determine the effectiveness of the training and determine if additional resources are needed.

Partnership’s Impact

In its service provision to people with physical disabilities, Partnership has had its greatest effect on the number of hospital admissions for ambulatory sensitive conditions. The rate of hospital admissions for diabetes, congestive heart failure (CHF), bacterial pneumonia, and chronic obstructive pulmonary disease has diminished by 43.9%, 61.3%, 37.2%, and 10.7% respectively in the year after enrollment as compared to the year prior to enrollment. Likewise, the length of stay for these conditions has also been significantly impacted, down 18.6% for diabetes and 71.6% for CHF.

DHFS also measures the achievement of desirable social outcomes that significantly impact a member’s quality of life. Members are interviewed to determine if their desired outcomes are met in the areas of self-determination and choice, community integration, and health and safety. Partnership has consistently compared favorably to other DHFS programs as well as to results of a national indicator. As architects of the Wisconsin Partnership Program, we are very proud of the program, and eager to share the accomplishments of the Partnership organizations and their members.