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Newsletter Article


Oklahoma's SoonerCare Health Management Program

The Oklahoma Health Care Authority has contracted the Iowa Foundation for Medical Care (IFMC) to administer the SoonerCare Health Management Program (HMP) for high-risk Medicaid members and primary care providers (PCPs). The program, launched in February, applies to the 65 percent of the state's Medicaid beneficiaries who are enrolled in SoonerCare Choice, a primary care case management program.

The two main components of HMP are:

  • nurse care management for high-risk members; and
  • practice facilitation for primary care providers.

The state uses MEDai, predictive modeling software, to identify SoonerCare Choice members who are at very high risk for adverse outcomes and increased health care expenditures. Once identified, the members are stratified into one of two levels of care. Tier-1 members are considered to be highest risk and receive face-to-face nurse care management. Tier-2 members are at high risk and receive telephonic nurse care management. Nurse care managers provide PCPs with monthly reports on their patients' status. Patients in both tiers receive the same services: monthly contact with a nurse care manager, assistance with customized self-management goals, education about the chronic illness, and pharmaceutical management. In addition, a behavioral health specialist and a community resource specialist are dedicated to the program (Figure 4).

Figure 4: SoonerCare Health Management Program: Services Available for High-Risk Patients

Nurse Care Management—Face-to-face or telephonic nurse care management provides education, support, self-management tools aimed at improving health, and care coordination.

Behavioral Health Screening—It is common for people with chronic health conditions to feel stressed or concerned about their health. In some cases, poor emotional health can make a medical condition worse. All HMP members will be asked to complete a behavioral health screening and, if needs are identified, will be referred to the HMP behavioral health specialist.

Pharmacy Review—With the help of nurse care managers, each HMP member will create a list of their medications. The nurse can ask for this list to be reviewed by a contracted pharmacy specialist if any problems are identified. This will lessen the chance of a medication error.

Community Resources—All nurse care managers and practice facilitators have access to a community resource specialist to help members locate appropriate resources.

Practice Facilitation—Medical professionals trained in practice facilitation work in providers' offices to enhance the efficiency and quality of care. These individuals work with the practice to set up a health information management tool to collect data and assess quality and performance to ensure evidence-based guidelines are followed.

Source: Okalhoma Health Care Authority,

The HMP uses practice facilitators to help primary care providers improve efficiency in quality care delivery. Each facilitator is a specially trained nurse or other health professional who works full time for one month, or longer if needed, in a SoonerCare PCP office. He or she assesses the care processes and identifies ways in which the office can work more efficiently, then provides education and helps to implement appropriate interventions. For example, one facilitator helped a clinic redirect patient flow and organize patients' charts, using flags with reminders of best practice guidelines. This led to more efficient patient flow and better care for high-risk diabetes patients.

After the initial month, facilitators follow up regularly with the practice to monitor adherence to the interventions and their effectiveness. They also help practices set up an electronic health management tool to assist in managing patients and their chronic diseases. Financial incentives are used to encourage provider participation.

Currently, six facilitators are working across the state with 10 practices that volunteered to have facilitation. Two more facilitators will join the program. The program plans to target provider practices with large numbers of high-risk SoonerCare members and hopes to involve at least 50 practices this year.

Finally, the HMP will organize regional, collaborative training sessions to enable participating providers to share lessons learned with other participants as well as non-participating providers.

Funding for the HMP comes from Oklahoma Health Care Authority's Medicaid Contracts budget. "We expect that, over time, the HMP will result in savings to Medicaid, making the program self-sustaining. When the program reaches its full capacity in all components, the state anticipates a budget of approximately 5 million dollars over five years," says Chambers. As of early June, about 30 percent of the 5,000 targeted members were participating in the program, working with about 35 nurse care managers.

"Every day, we're learning how to engage members more effectively and efficiently," says Dora Chambers, IFMC's HMP project director. "We've already changed our outreach approach, to use a more personal and comforting touch." Administrators also have learned that behavioral health is a major factor in this population. "About 40 percent of our high-risk members are referred to the behavioral health specialist," says Chambers.

For More Information
Contact: Dora Chambers, IFMC Project Director, SoonerCare Health Management Program, Iowa Foundation for Medical Care, (866)539-0365 (toll free).

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