Thursday, May 1, 2014

MMCC Podcast Series with Dr. Tomas Gonzalez of STAR+PLUS & Cigna-HealthSpring

Here is a teaser from our podcast series with Dr. Tomas Gonzalez
Dr. Tomas Gonzalez, Senior Medical Director, STAR+PLUS, Cigna-HealthSpring

I know you’ll be speaking at the 2014 Medicaid Managed Care Congress. So, hopefully this will give folks a little bit of a preview of what your talk is going to be like in Baltimore in May.

Tell us a little bit about the program itself, just the “who” in terms of the care providers, the patient profile, the “what” – the care model – and the “where” in terms of the care setting.

Dr. Gonzalez: Back when Medicaid Managed Care arrived in South Texas in March of 2012, we immediately saw a challenge with our most intense and high acuity psychiatric patients. When we did a financial analysis of those patients, we saw many readmissions to the same hospitals and a high utilization rate. In fact, out of our 20 most expensive and high-utilizing members, we found that more than half of them were psychiatric patients. Nevertheless, we decided that we had to do something about these high utilizers – very, very critical – so that they could live more independently in the community.

In South Texas, there is a group called: “The Psych Nurse”. That’s the name of the company – The Psych Nurse Incorporated. They were traditionally a home-health psychiatric nurse provider for the Medicare product because in Texas, home health for psychiatry is not a covered benefit under Medicaid. So, it was a challenge and, internally at Cigna-HealthSpring, we needed to figure out how to engage the Psych Nurse because they have a very good reputation in the community and because they have a history of doing good work with the utilizing psychiatric patients.

We felt we needed to take the opportunity to engage with the Psych Nurse to be partners and help us manage this population. So, what we did was engage the Psych Nurse and say: “I think you all have what it takes. Your model of looking at the entire person, looking at the health and looking at the well-being and the independence of the psychiatric patient instead of looking at a finite number of visits per patient is going to be the right approach.” So, it took several planning sessions and we finally came to an agreement with the Psych Nurse that we would send them our sickest and our highest utilizing, highest cost members.

The framework of the program was kind of open. It was an open approach in that I would send them the name of a patient with a prior authorization for an extended amount of time – 99 visits. The Psych Nurse was then given free range to see those high-utilizing psychiatric patients as often as they thought they needed to see them – daily, every other day, seven times a week, ten times a week – whatever it took to help the patients live independently.

Now, keep this in mind. This was not a hospitalization avoidance program. Many people like to slot this program into that kind of peg. That’s not what it was designed to do at all. The program is designed to help the patients to live independently out of jails, hospitals, nursing homes and live in their home or choice of homes out in the community. So, when the Psych Nurse engages one of these members, of course, like many psychiatric patients – and these are the sickest of the sick. These are the refractory schizophrenics, the non-compliant bipolar patients, the dual diagnosis patients with polysubstance abuse and other Axis I disorders. These are the patients who many, many have discarded, many have considered un-helpable and many have considered the drain on the system that no one can really fix. Well, as we engaged these members through the Psych Nurse and we had weekly rounds with me, the Medical Director and a Psychiatrist – I am a psychiatrist – we brainstormed plans, strategized how we’re going to help these members understand 1) their medication compliance, 2) their desire and hope and need for sobriety and 3) getting families involved as much as possible. I think the Psych Nurse is extremely skilled in getting these patients to understand their own health, their own need for continued and improved mental clarity and their families.

South Texas, as you probably know, is heavily Hispanic. Mostly Mexican American. About 90% of the population is Mexican American and many of our patients only speak Spanish. The Psych Nurse is homegrown, pretty much. They are RNs – and that is the only type of nurse that we allow to see the patient. RNs – Registered nurses – who will bond with these patients in their culturally appropriate and culturally sensitive way. Some only speak Spanish. Well, our nurses only speak Spanish. 

Dr. Gonzalez will be speaking at the 22nd Annual Medicaid Managed Care Congress, May 19-21 in Baltimore, MD. To learn more about the event, click here. Save 15% off the standard registration rate when you use the code: XP1926BLOG

Register here.

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