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Since 1997, more than 420,000 Alabama Medicaid recipients – 80 percent children – have been assured access to a basic medical home through Patent 1st, the Agency’s Primary Care Case Management (PCCM) program. The statewide program operates under the authority of a 1915(b) wavier.

 
Alabama is working to enhance its Medicaid PCCM program by developing community networks that will support primary care providers in becoming medical homes. Among other services and functions, the Patient Care Networks of Alabama (PCNA) will help primary care providers coordinate care for high-needs and high-risk patients and teach self-management skills. The objectives of the PCNA Care Management Program are to:
  1. Develop and implement patient centered holistic plans of care;
  2. Improve quality of care and quality of life;
  3. Improve health literacy, health outcomes and self management;
  4. Improve utilization of Information Technology resources by participants and providers in PCNA as available;
  5. Promote effective use of the healthcare system and community resources;
  6. Reduce the potential for risks of catastrophic or severe illness;
  7. Prevent disease exacerbations and complications;
  8. Integrate use of evidence-based clinical practice guidelines into PCNA practices to ensure the “right care at the right time;” and
  9. Reduce inappropriate utilization and costs associated with Emergency Department and hospital inpatient services.
The networks will provide population health management by:
  • systematic data analysis to target recipients and providers for outreach, education, and intervention;
  • monitoring system access to care, services, and treatment including linkage to a medical home;
  • monitoring and building provider capacity;
  • monitoring quality and effectiveness of interventions to the population;
  • supporting the medical home through education and outreach to recipients and providers; and
  • facilitating quality improvement activities that educate, support, and monitor providers regarding evidence based care for best practice/National Standards of Care.

Networks provide care management by:

  • advocating for high risk, high acuity recipients to ensure that recipients receive appropriate evidence based care; and
  • educating recipients about disease states and self management.
On May 31st, 2011, The Centers for Medicare & Medicaid Services (CMS) provided the necessary authority for Alabama to launch the program in the second half of 2011.
 
Alabama has received a Section 2703 Health Home planning grant, and the planning period is scheduled for September 2011 - August 2012.
 
Targeted population: Medicaid/CHIP
 
For more information on Patient 1st and PCNA, please visit:
 
 
Last updated: September 2011

 

Forming Partnerships
The Alabama Medicaid Agency has established working relationships for this project with the state physician associations (including the Alabama Chapters of the AAP and AAFP), the Alabama Primary Health Care Association (representing FQHCs in the state), the Department of Public Health (CHIP program administrator), and the Department of Rehabilitation, among others. In addition, a reengaged and expanded Patient 1st Advisory Council that includes Family Voices and several physicians is guiding the Agency’s work. Alabama held town hall-style meetings with provider around the state to discuss the new community network program. Patient Care Networks will be organized as 501(c)(3) corporations. At least one half of the Board of Directors for each network must be comprised of primary care physicians, and in addition the Board must also include at least one representative from a Federally Qualified Health Center, a hospital, the health department, a Regional Public Mental Health Authority and a community pharmacist. This composition encompasses representatives from across the community and will aid in support of practice transformation.
Defining & Recognizing a Medical Home
Expectations for Patient 1st primary medical providers (PMPs) can be found in the Patient 1st Handbook. No formal recognition standards are being used at this time. Alabama’s definition of a medical home includes the following components:
  • Has a licensed physician, enrolled in the Alabama Medicaid Program, who has not been sanctioned.
  • Accepts enrollees and is listed as in the Patient 1st Directory for the purpose of providing care to enrollees and managing their health care needs through the Medical Home concept.
  • Provides for hospital admissions.
  • Provides primary care and patient care coordination services to each enrollee in accordance with the policies set forth in Medicaid provider manuals and Medicaid bulletins and as defined by Patient 1st policy.
  • Provides or arranges for primary care coordination and coverage for services, consultation or referral, and treatment for emergency medical conditions, twenty-four (24) hours per day, seven (7) days per week as defined by Patient 1st policy. Automatic referral to the hospital emergency department for services does not satisfy this requirement.
  • Provides EPSDT preventive care screenings to Medicaid eligible children age birth through 20. PMPs serving this population who do not provide EPSDT services are required to sign an agreement with another provider to provide EPSDT services. PMPs must retain a copy of this agreement in their files and must ensure that their records include information regarding the extent of these services.
  • Maintains a unified patient medical record for each enrollee following the medical record documentation guideline as defined by Patient 1st policy.
  • Promptly arranges referrals for medically necessary health care services that are not provided directly and document referral for specialty care in the medical record. Provide the authorization number (NPI) to the referred provider.
  • Transfers the Patient 1st enrollee’s medical record to the receiving provider upon the change of primary medical provider at the request of the new primary care provider and as authorized by the enrollee within 30 days of the date of the request. Note: Patients must request their records be transferred to the new PMP and must not be charged a fee for this service.
  • Authorizes care for the enrollee or see the enrollee based on the standards of appointment availability as defined by Patient 1st policy.
  • Refers for a second opinion as defined by Patient 1st policy.
  • Reviews and uses all enrollee utilization and cost reports provided by the Patient 1st program for the purpose of practice level utilization management and advise the Agency of errors, omissions, or discrepancies.
  • Reviews and uses the monthly enrollment report as required by Patient 1st policy.
  • Participates with Agency utilization management, quality assessment, and administrative programs.
  • Provides the Agency or its duly authorized representatives and appropriate Federal Agency representatives unlimited access (including onsite inspections and review) to all records relating to the provision of services under the provider agreement as required by Medicaid policy and 42 C.F.R. 431.107.
  • Maintains reasonable standards of professional conduct and provide care in conformity with generally accepted medical practice following national and regional clinical practice guidelines or guidelines approved by the Patient 1st Advisory Group.
Aligning Reimbursement & Purchasing
Under the state’s new regional pilot to support primary care providers to function as medical homes through Patient Care Networks, Medicaid will pay the networks $3PMPM for members of the non-ABD population and $5 PMPM for members of the ABD population. Additionally, Medicaid will pay an additional $1.60-$2.10 PMPM care management payment to participating network providers on top of the base $1.00 Patient 1st care management PMPM. Medicaid varies the additional network provider payment based on the patient panel’s average acuity level.
Supporting Practices
Alabama is developing three pilot patient care networks (the geographic regions were selected with stakeholder input), to support providers with services including:
  • quality improvement;
  • pharmacy assistance;
  • care management; and
  • general medical home maturation.
The networks will each develop initiatives around topics that have already been identified (high cost/high co-morbidity patients, asthma, diabetes, etc.) and topics that will be defined through mutual agreement. One of the state’s strategies to support and sustain provider change is through information technology. With a Medicaid Transformation Grant in 2007, Alabama Medicaid is working with primary medical providers (PMPs) to help them adopt the use of the QTool, the Agency’s electronic health record and clinical support tool. Additionally, PMPs have access to in-home monitoring program data that allows patients to record certain vital signs and/or test results at home and transmit the data to a central repository. Patient 1st PMPs receive a quarterly physician report card, known as the Profiler, which contains summary information on a PMP's panel for 12-month period. The Profiler contains information on how a particular PMP compares with his or her peers on certain key quality and cost measures. Alabama has begun work to create a system to reimburse and integrate community pharmacists/pharmacies for their cognitive and professional services.
Alabama is planning to have an outside entity perform CAHPS surveys for a baseline and post-implementation evaluation for measuring progress within each community network pilot. Additionally, the state will perform a pre- and post-financial analysis. Key outcomes of interest for the community network pilots will include improved clinical outcomes, improved patient satisfaction, and Medicaid cost containment. Specific measure that will be used include CAHPS survey results, Emergency Department utilization for asthmatics, Hemoglobin A1C Measures for diabetics, inpatient hospitalization, immunization rates, and average number of office visits. The University of Southern Alabama is assisting with evaluation design. The Alabama Healthcare Improvement and Quality Alliance Workgroup – a public/private effort – is working to collectively establish measures predicated on national standards that can be used to assess progress on all programs throughout the state.
 
No further information is available.