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

 
Alabama is enhancing its Medicaid PCCM program through community networks that support primary medical providers (PMPs) in becoming medical homes and delivering key services to patients. As of January 2012, the program serves approximately 80,000 Medicaid enrollees. About 40 full-time equivalent staff members, working for one of three networks, serve high-needs and high-risk enrollees. Approximately 135 PMPs are receiving enhanced payment from Medicaid to work in partnership with the network staff. The program began in August 2011.
 
Among other services and functions, the Patient Care Networks of Alabama (PCNA) help PMPs coordinate care 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 the 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 provide population health management through:
  • 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 patients about disease states and self management.
As of January 2012, there are three networks in Alabama with a combined annual budget of about $3.5 million. Each serves patients and providers in a defined geographic area. The state is considering options for expanding the PCNA program going forward.
 
Visit the Patient 1st Handbook to learn more about that program. Further information on PCNA is available on the PCNA homepage, as well as in the original request for proposals.
 
Federal Support: On May 31, 2011, the Centers for Medicare & Medicaid Services (CMS) provided the necessary 1915(b) waiver authority for the state to launch the Patient Care Netowrks of Alabama program in the second half of 2011.
 
Alabama has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions.
 
Last updated: January 2013
 
 
Forming Partnerships
The Alabama Medicaid Agency has established working relationships for this project with the state physician associations (including the Alabama chapters of the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP)), the Alabama Primary Health Care Association (representing federally qualified health centers (FQHCs) in the state), the Department of Public Health (Children’s Health Insurance Program (CHIP) 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 Patient Care Networks of Alabama (PCNA) program.
 
Each Patient Care Networks of Alabama (PCNA) network is organized as a 501(c)(3) corporation. 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 an FQHC, a hospital, the health department, a Regional Public Mental Health Authority, and a community pharmacist. This composition encompasses representatives from across the community to support 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 Early Periodic Screening, Diagnosis, and Treatment (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
For the Patient Care Networks of Alabama (PCNA): Medicaid pays the networks $3.00 per member per month (PMPM) for each assigned enrollee who is not aged, blind, or disabled (ABD). The fee is $5.00 PMPM for each assigned ABD enrollee. Networks are also eligible for up to $50,000 in reimbursement for start-up costs.
 
For primary medical providers (PMPs): PMPs who have agreed to partner with their area networks are receiving a $1.60-$2.10 PMPM care management payment. This is in addition to the $1.00 Patient 1st care management PMPM that has traditionally been paid to all Patient 1st PMPs. Medicaid varies the additional network provider payment based on the average acuity level of each PMP’s panel.
 
Since 2004, Patient 1st PMPs have been eligible to receive shared savings payments that vary in accordance with performance on certain quality benchmarks. As of late 2011, PMPs outside of PCNA network areas are still receiving these incentive payments. Further information, including shared savings methodology, is available online here.
Supporting Practices
Alabama has launched three patient care networks run by Patient Care Networks of Alabama (PCNA) in select counties to support primary medical providers (PMPs), with services including:
  • Quality improvement;
  • Pharmacy assistance;
  • Care management for high-risk and high-needs patients; and
  • General medical home maturation.
The networks are each developing 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 PMPs to help them use 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 Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys for a baseline and post-implementation evaluation of change in patient experience 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 measures that will be used include CAHPS survey results, emergency department utilization for asthmatics, HbA1C 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.
 

 

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