Brief Overview:

Gold Choice PCMPIIA, as it is known today, was born in 1994 due to the efforts of many fine individuals and organizations that saw a need for a Medicaid Managed Care Program for recipients with special needs.  This population consists of Medicaid beneficiaries who are chronically and persistently mentally ill and or in substance abuse treatment, who have historically experienced poor coordination of care. 

In 1994 a small but motivated team of individuals set to the task of setting up such a program.  It was agreed that three primary long-term goals must be met in order to succeed in such an undertaking:

• First and foremost, access to and availability of primary and acute medical health care services must be enhanced.
•  Quality of care within the program must be ensured.
• A cost-effective model must be established.

Within two years (in conjunction with UB Family Medicine, Inc.) the Gold Choice team established the following:

• A network of primary care providers
• Procedures for enrollment, disenrollment, and managed care program transfers, provider change protocol, grievance/members rights protocol, and marketing and education practices.
• A management information system, utilization reviews protocol, and quality assurance protocol.

Once orientation, training, and educational sessions with area special care agencies were in place, Gold Choice was ready to begin enrolling members.  In the first months Gold Choice went from 2 members to 12, to processing over 800 applications per month.  Today Gold Choice has over 4,000 enrollees with 200 applications being processed monthly.

Gold Choice continues to work towards structuring a seamless health care system, which facilitates and promotes communication between it’s two member organizations: primary care and specialty care. 

Mission Statement:
The mission of the Gold Choice PCMP IIA is to work in partnership with the participating primary care providers and the associated chemical dependency and behavioral health agencies to continually improve the quality of care and service delivered to Gold Choice members. The goal of the program is to encourage the delivery of optimal services at the appropriate time and in the most effective manner.

Strategic Objectives:

1. To expand collaboration and coordination with all community resources to meet the complex needs of enrollees including those with an alcohol and/or substance abuse problem;
2. To provide training to primary care physicians regarding the unique risks associated persons in special populations including individuals with an alcohol and/ or substance abuse problem;
3. To support the continued development of proactive provider practices including case management/ service coordination services;
4. To improve evidence-based interventions and performance measures over time; and,
5. To facilitate patient empowerment by actively encouraging their self-management.
   

PCMP: Physician Case Management Program

The primary care provider is responsible for the coordination of medical care for Gold Choice members.  This includes referring members for specialty care and providing authorization for those services.  Services not authorized by the PCP are not compensated by Medicaid.  The provider is responsible for providing 24-hour access to care on a non-emergent level.  Mental health and substance abuse services are to continue to be provided by the special care agency without a referral from the PCP.

Case Management:

The purpose of the Gold Choice Case Management Program is to coordinate and integrate access to primary and specialty care for the membership and to link members with other needed medical and other support services available in the community.

In addition to service coordination and linkage, the case management staff also provides health education that teach individuals about the value of proper medical follow-up, immunizations, HIV related information, Sexually Transmitted Diseases, as well as preventive health activities like good nutrition, and exercise.  Gold Choice may also refer individuals to a Wellness program where individuals receive one to one consultations on health and wellness.  In addition, through specialized training of primary care physicians, quality assurance functions and the case management follow- up the program ensures that prescription of medications are not counter- indicated against risk factors associated with specific mental disabilities.  All such services are coordinated with the mental disability providers (e.g., chemical dependency) from whom enrollees are receiving services.  These services not only ensure that higher quality medical service are received by enrollees, they also relieve the chemical dependency provider of similar case management and follow through activities related to co- morbid medical problems.  Finally, the program has a case manager available one day a week in the drug courts to help people enroll in Gold Choice, provide education and linkage in the community.

Gold Choice has developed in-house protocols that define the type of service that should be provided to any consumer at any given time.  The program has defined its case management services into three levels.  Each level provides for the type and degree of response as defined by the relative risk of each enrolled individual.

Level One is supportive case management.  These services are provided by phone by trained member services individuals that are available Monday – Friday/8:30 am – 4:30 pm. 

1. Re-linkage of primary care physician; change of PCP.
2. Access to emergency services.
3. Client education.
4. Informal client grievances.
5. Trouble shooting access to specialty care services.
6. Financial Case Management.

Level Two is pre-comprehensive case management.  These services are provided by trained case management staff, e.g. registered nurses either by the phone or face to face at a PCP office or counseling site.  Level Two is basically defined as the same issues listed in level one but take multiple phone contacts and conversations with either providers or consumers to solve the issue.

1. Determine client need for extensive service that is related to issues in level one.
2. Determine if service is needed in the community, e.g. meet a consumer at the  medical office to provide support during the medical visit.
3. Provide client education, e.g. personal hygiene/health, reinforce prescribed medical treatment plan, program benefit, access to services, grievances.
4. Social support, e.g. reconnect to family, friends, and community resources.
5. Link to other health care providers.
6. Track all inpatient and detox’s through weekly reports using this information the case manager monitors appropriate and inappropriate usage and will work with the member and chemical dependency counseling agency for better linkage and care. 

Level Three is comprehensive case management.  At this point in our program, this level of service is provided to all children in the program, and those that qualify for the Erie county Demonstration Project provided by Spectrum Human Services for individuals that have multiple inpatient detoxification and/ or rehabilitation admissions during the course of a given year. 

1. Assessment
2. Service plan development
3. Medical record evaluation
4. Linkage to entitlements
5. Housing issues
6. Legal issues
7. Linkage to health care or other providers.
8. Accompany client to medical appointment.
9. Linkage to Social Services
10. Multidisciplinary team case management approach.
11. Organize access to community medical services.

Clinical Studies:

All members of Gold Choice, after enrolling, are asked to fill out a Health Risk Assessment.  This assessment gives detailed information on co-morbid conditions, the last time the member had a medical visit, ER usage and disability information.  This is used to determine what type of linkage is needed in the community.  A case manager tracks the information and follows-up with the members to ascertain needed referrals and proper ER education to reduce unnecessary visits.

The goal of the Gold Choice Health Risk Project is to develop a case management intervention system that will benefit the Gold Choice client by providing appropriate intervention programs for those clients identified at high health risk and with a willingness to improve their health. 

This information is also used along with our encounter data (supplied by the PCP) to run our clinical studies which focus on asthma, diabetes, hypertension, coronary heart disease and congestive heart failure.  Currently we are focusing on diabetes to ensure that our members have appropriate care, follow-up with specialty care if needed, nutrition, and medications. The purpose of these studies are to ensure that evidence-based treatments that reduce morbidity and mortality for a specific disease will be utilized in the care of our patients.

Overall, from our encounter data alone, over 40% of the chemically dependent members enrolled,(who have seen their Primary Care Physician) have been diagnosed with either asthma, diabetes, hypertension, coronary artery disease and/or congestive heart failure.