Chronic disease is the leading driver of the United States’ $3.5 trillion in annual health care costs. More than 80 percent of Medicaid’s expenditures are spent on adults with chronic conditions. Chronic diseases are not only expensive, but they are also pervasive. About 60% of adults in the US have a chronic condition.

Managing care for this population is essential but difficult. The Medicaid Value Program: Health Supports for Consumers with Chronic Conditions, an initiative designed by the Center for Health Care Strategies, Inc. and funded by Kaiser Permanente and the Robert Wood Johnson Foundation, set out to find innovative ways to improve care delivery for Medicaid recipients with multiple chronic conditions. 

Through their case studies, lessons can be learned, and innovation can be sparked to help find ways to improve health outcomes and reduce unnecessary health incidences and costs. Here is a summary of some of the approaches taken.

Address Social Determinants of Health 

The Care Oregon Complex Care Support Program

 This program aimed to expand and leverage care management to address factors that hinder proper care for members with chronic conditions. This included addressing mental health needs, but it also expanded to include addressing social issues, such as housing insecurity, substance abuse and addiction, and lack of social support systems. 

Integrate House Calls 

District of Columbia Department of Health, Medical Assistance Administration

 This initiative used the Medical House Call Program to assist chronically ill seniors. The program would make home visits to provide case management and to coordinate care. By providing in-home visits, the program aims to reduce end-of-life hospitalizations, hospital lengths of stay, emergency room visits, and nursing home placements.

Address Mental and Behavioral Health Care Needs

Johns Hopkins HealthCare LLC

 This program expanded care management for Medicaid beneficiaries with both chronic illness and mental health or substance abuse. This included helping patients with care integration, self-management, and referrals to community resources. 

Targeting Case Management

Managed Health Services, Inc.

 This project tested predictive modeling and health risk assessment screenings to determine how to improve the case management of consumers with multiple chronic conditions. They also studied the relationship between case management and hospitalizations, and emergency room utilization.

Improve Health Education 

McKesson Health Solutions

 This project looked at the effectiveness of diabetes group education for aged, blind, and disabled Medicaid consumers. 

Utilize a Health Care Navigator

Memorial Healthcare System

 Most Valued Partner (MVP) Program integrated a Health Navigator into the disease management team to develop care plans based on each individual patient’s needs. They also addressed barriers to care, referrals to community resources, and encouraged other productive behaviors.

Integrate Care

Washington State Department of Social and Health Services

 The program integrated primary care, mental health, substance abuse services, long-term care, and disease management for the target population using intensive and ongoing case management services. 

Improving outcomes for patients with chronic disease is a monumental undertaking that requires innovation, as represented in these case studies.