Medicaid Integrative Therapies Pilot, #2: Holistic Nurse Management of Massage and Acupuncture, Plus
Written by John Weeks
Medicaid Integrative Therapies Pilot, Part 2: Holistic Nurse Management of Benefit for Licensed Massage and Acupuncturist, Plus
Summary: Imagine you
have the opportunity to create an integrative therapies program for a chronic pain population. Your boss is the Florida state
legislature. For the first time, thanks to a Medicaid waiver, limited
services of massage therapists and licensed acupuncturists can be
included. Your outcomes
will be measured and published. What goes into such a program? How does
one manage it? Such was the problem set and opportunity handed Alternative
Medicine Integration Group (AMI) when the firm won a contract under the
Florida MediPass program in 2003. So far so good for AMI: Florida's
legislature extended the contract in 2007 following reports of positive
clinical and cost savings. This article, Part 2 of a 5-part series, examines the management and care process.
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1. At the center of the care process: holistically-oriented nurse case managers
"We re-invent ourselves every day." Tracy Woolrich, RN, HHP,
laughs heartily over the phone as she reflects on the care management
processes with which she is involved. Woolrich is one of two nurse case
managers who oversee a fluctuating group of 400-500 high-cost, chronic
pain clients who are participating in a unique pilot program which is paid under Florida Medicaid.
Florida Medicaid - grants waiver for services of licensed acupuncturists and massage therapists
What particularly excites Woolrich is that she is engaged in a care
model which makes use of that "HHP" after her name. Following personal
interests, Woolrich completed a program to earn certification as a Holistic
Health Practitioner.* Her clientèle are the first population in U.S. history who have access to covered services provided by
credentialed networks of licensed acupuncturists and massage therapists
which are directly paid through Medicaid. In her case management,
Woolrich also dispenses integrative medicine-oriented self-care
educational materials, and condition specific mind-body CDs. From time to time, Woolrich manages support groups. Woolrich is a participant's first phone
contact as they sign up to participate and is a telephonic coach and
liaison while they participate.
"What is so wonderful is that I am finally doing what I wanted to do,"
recalls Woolrich. Before the job, she worked as a hospital-based nurse
and in conventional case management. But this is different: "This job
is giving me the opportunity to do healing. It's not like anything
I've been able to do before." She reflects on her former work as an
oncology nurse: "It's not like traditional nursing, that's for
sure."
Tracy Woolrich, RN, HHP - holistic case manager
Woolrich's opportunity came through a pilot project approved by the Florida state legislature in 2002. Alternative Medicine Integration Group (AMI) of Florida, LLC, an affiliate of Chicago-based AMI, an Integrator
sponsor, won the contract to develop the pilot. AMI is on the hook to
show that the pilot is producing positive cost and clinical outcomes.
Their ability to do so led to an extension in 2007. (See Medicaid Integrative Therapies Project, Part 1: An Overview.)
Interviewing Woolrich about her role makes it abundantly clear that any positive
outcomes in this pilot project must be attributed, in part at
least, to the program's deeply committed nurse case manager. Indeed,
patient surveys and interviews (see Part #3, not yet published) underscore
the esteem in which Woolrich and her associate are held.
2. PCP participation - connecting with the high-cost, chronic pain clientèle
The AMI project began in 2004, offering treatment to beneficiaries of MediPass, Florida's Medicaid plan, in a three county area surrounding St.
Petersburg.
In the 2004-2007 phase of the pilot, the
patients also needed to meet an additional criterion: they needed to
have a primary care doctor who wanted to, or was willing to, have his or her patients
participate in the program.
Florida's Medicaid program
Woolrich or AMI's executive in charge of the Florida
operation, Adrian Langford, began meeting with the doctors.
Their goal was to have a signed Memorandum of Understanding (MOU) with
each. "We tried to get them all to participate," said Woolrich. "Some were very good
and interested, some said 'whatever,' some just said 'leave me alone,'"
she recalls. In time, roughly 60-65% of the eligible doctors
signed MOUs.
Once the PCP was on board, the physician could directly refer patients.
But this direct physician referral netted only a minor fraction of participants. Most patients - 99%
was Woolrich's off-handed guess - came from lists the state released to
AMI monthly. These were patients from the approved physicians' MediPass patients
who had one of the 4 chronic pain diagnoses. (See below.) Each month, the state sends AMI a list with 100-300 names on it.
AMI's recruitment of patients included phone calls and direct mail which described potential benefits of massage and acupuncture . Roughly 1/3 of those who
received the card called up. Woolrich and her colleague called the
others. "With some we left a voice mail once a month for a few months before making contact,"
notes Woolrich, adding that "eventually we capture about 1/2 to 2/3" of
the eligible individuals.
3. Clientèle not that of your typical boutique, cash-based, integrative practice
Woolrich, who clearly enjoys working with the AMI clients, acknowledges that they can be a challenging population, both clinically
and from a management perspective. The core criterion is that they must be MediPass beneficiaries with one of four conditions:
fibromyalgia
chronic back pain
chronic neck pain
chronic fatigue.
Many are disabled and suffering with multiple conditions.
Among them are individuals who are home bound. Others are agoraphobic. Quite a few are obese. Many have
multiple health conditions compounded by injuries. Some are
paraplegic. A number have significant substance issues.
Woolrich notes that some work in their acupuncture and massage treatments around their
addictions. Woolrich describes a customer who comes in for his
treatment on the 2nd and 4th weeks of the month because "he's drinking
the first week" after a monthly check arrives.
In addition, most are on
very limited income. Says
Woolrich: "We've learned to make our calls in
the first 2 weeks of the month as many have cell phones for which they
buy minutes. They're run out of minutes by the end of the month and we
can't reach them." Woolrich reflects: "It's kind of a gypsy
group. They move around a lot. Only 80%-85% of the addresses work in a
given month." 4. Access to massage therapists, acupuncturists and chiropractors
AMI's management of these patients was conceived as an add-on of
an integrative program to the core treatments already available. In
Florida, this meant the conventional services as well as access to
chiropractic care through chiropractors who were already providers
under Medicaid. AMI's nurse managers routinely provided their patients
with the lists of chiropractors in the area who participated with
Medicaid. The basic chiropractic benefit is 10 visits per year unless they have a script from their PCP, in which case they can have up to 24 treatments.
Illinois-based AMI's Florida affiliate created the program
Part of what AMI
was to measure was whether the use of the integrative therapies had any
effect on per member per month costs for usual and customary care for
such a population.
The new covered benefits for which the state of Florida applied,
successfully, for a waiver, are those provided by licensed
acupuncturists and licensed massage therapists. Under the AMI program,
participants have up to 2 visits per month to either an acupuncturist
or a massage therapist. The patient and nurse manager decide together which type of practitioner he or she will
use. The participant and nurse case manager can decide to change this at some point in the treatment. Says Woolrich: "It
is a very fluid process with many variables and solutions." Patients have started with massage and switched to acupuncture, and vice versa.
Roughly 3/4 of the participating MediPass patients begin with massage therapists. Woolrich says concern about needles appeared to be part of the resistance to acupuncture but that, notably, this did not seem to be a much of a concern in the Hispanic population as it is with Caucasians and African-Americans.
Woolrich and Langford, AMI's Florida-based executive, underscore that
the benefit structure allows some patients, from time-to-time, to have
more than two visits per month. This is possible through program
features which allows one patient to have access to a massage or
acupuncture visit not used by another client. With this flexibility,
some clients may be able to have a treatment a week for the first
month, or even two treatments in a week to get started. The average
over time is 2 per month.
To deliver the treatments, AMI-credentialed networks of massage
therapists and licensed acupuncturists, or Acupuncture Physicians (AP),
as they are called in Florida. Woolrich says that in the tri-county
area, AMI has a growing network which included 55 massage therapists and 23 acupuncture physicians as of early November.
The number of acupuncture or massage visits a patient can receive in a month is sometimes increased through a separate process in which AMI's practitioners practitioners
agree to offer "split sessions." Basically, the practitioner only
bills for 1/2 the fee during a visit, allowing the person additional treatment. Woolrich estimates that 25% of the network acupuncturists and massage therapists volunteer to do this from time to time.
5. Agreements and fees for the licensed massage and acupuncture practitioners
Each of the massage therapists and acupuncturists who contracted with
AMI agreed to participate with the AMI management plan. First, they
accepted a fee schedule. The per-fee payment, which AMI preferred not
to disclose, is the same for massage or acupuncture.
Together, the patient and nurse
manager decide which type of practitioner the patient will
use. The two can decide to change this. Patients
have started
with massage and switched to acupuncture, and vice versa. Says Woolrich: "It
is a very fluid process with many variables and solutions."
The per visit fee was lower than most of the practitioners typically charged in their cash practices. Those who the Integrator interviewed who participated in the pilot gave a variety of reasons for accepting the fee schedule: the clientèle was interesting, the income was steady, and the insurance
paperwork was not viewed as too onerous. (Part 3 will include information from interviews with members of AMI's massage therapist and acupuncture physician networks.)
In addition, participating practitioners were not limited to using a portion of their clinical toolkit as they are in certain integrated and covered-services environments. AMI's acupuncturists are allowed to use all therapies which are in their licensed scope of practice. However, the same flat fee was paid by AMI for whatever treatment was offered.
6. The encounter form for the outcomes-based pilot
AMI's outcomes-based business model and the reporting mandates the Florida legislature placed on the pilot each required atypical documentation. AMI needed to capture some basic information in order to analyze changes. Participating practitioners needed to help with the data gathering.
The centerpiece of AMI's routine analysis is a one page encounter form filled out with each visit. The form includes both clinical and payment information. Says Woolrich: "It's both a billing and communication form." Elements include:
Basic subjective/objective SOAP information.
A 1-10 Likert scale on the patient's pain level.
A box to check-mark if any educational or self-care documents were handed out.
The form is faxed to AMI Florida which then sends a copy each month as a communication tool to the the patient's primary care provider. Information from the form is also sent to AMI's Illinois as a basis for billing. AMI paid practitioners monthly.
7. Self-care materials and use of groups
The care Woolrich describes has the individualized, whole-person characteristics which typify treatment as provided by many licensed complementary and integrative care practitioners. Treatment plans - and thus the research outcomes - are not based on a protocol in which each individual receives as close to identical inputs.
The whole system of care available to the holistically-oriented nurse
under AMI's integrative therapies pilot includes more than the skills
of the acupuncturists and massage therapists. Other tools include:
Written handouts - AMI has 14 self-care brochures which either the nurse manager or a network practitioner could give to a patients. Those used most often are here, with Woolrich's descriptors:
“Living with pain” (dealing with, not just treating, pain)
“Holistic health” (using the best of both worlds; includes a 10 question 'health test')
“Overcoming stress” (how to overcome the stress before it overwhelms you)
“Living with Fibromyalgia” (reminds you that control begins with you).
Condition-specific CDs - The program uses the condition-specific programs developed by Belleruth Naparstek and distributed through her company, Health Journeys.
Groups - AMI has developed a list of 20 support groups in the Tri-County area they serve. From time to time patients may be referred to these.
Woolrich has found that some of AMI's credentialed massage therapists and acupuncturists are fond of using the written handouts with their patients. Others are not. Woolrich estimates that 75% of the practitioners use them. She notes that the acupuncture physicians who are Chinese are "not as likely to use them." 8. Nurse intake and case management - "a chance to focus on wellness"
I asked Woolrich to reflect on the difference between her case management experience with the AMI pilot and the case management work she was accustomed to doing as a hospital nurse.
"When I was in hospital-based case management," Woolrich responded, "our
goal was lowering length of stay. We were trying to get people out of
the hospital." (Because hospitals are frequently paid a set amount for a
patient with a certain condition, moving patients through is critical
to their bottom line.) Woolrich adds that she "felt aligned" about that mission: "Moving them out
diminished their chances of getting hospital-based infections, or
facing medical errors." She did hot feel she was potentially adding to harm by rushing a hospital process.
"We typically start with a 30-minute phone
interview. I get to know them. I have the
opportunity to help guide them ... There is a chance to focus on
wellness, for wellness coaching."
- Woolrich
Woolrich acknowledges that an outpatient program such as the AMI pilot, in which she is involved with patients over time rather than for an acute episode, by its nature creates a context in which she can be more deeply engaged with patients. "We typically start with a 30-minute phone interview," she explains. She adds: "I get to know them. I have the opportunity to help guide them."
While Woolrich feels like she doesn't "really know them until I have a chance to see their home," this rarely happens.
She only ever meets 10% of the clients face-to-face. Yet as the phone encounters increase the relationship changes: "Usually after 2 or 3 calls their story begins to come out." And this allows the relationship to deepen: "There is a chance to focus on
wellness, for wellness coaching."
As they get know know them, Woolrich and her fellow nurse manager often make individualized judgment calls about the clients. An example is the use of the Health Journeys mind-body CDs. These cost AMI $10-$12 each (Medicaid does not reimburse them, so they are an AMI-sponsored value addition to the program.) Before the nurses send one to a client, they will first look for signs that the client is making a personal commitment to their own health. Woolrich tries to discover if they are on any kind of personal wellness program. She adds: "Maybe it's just learning that they are taking supplements. " If she has a positive instinct, she then makes sure they have a CD player. Woolrich estimates that AMI has "probably sent out a couple hundred." 9. Evolution of the program
When Woolrich speaks of AMI's team "re-inventing ourselves daily," she refers to the firm's service focus and efforts to respond to client need. For instance, AMI learned early on that "the biggest complaint was that (patients) couldn't get enough treatments." This birthed the idea of asking practitioners to voluntarily "split" a visit. In effect, practitioners offer a treatment for free - something that practitioners of all kinds in community medicine do daily.
AMI has also sought to respond to needs of homebound clients by offering acupuncture and massage home visits. Woolrich has also made home visits on rare occasions to facilitate development of an optimal treatment plan to fit the patient's needs.
AMI viewed the Health Journey's CDs as potentially valuable help for some of their clients. They chose to internally fund these tools.
Another example of AMI's attempt to be responsive is AMI's decision to initiate a support group program to fill a gap in community services. "We found out that everything we needed wasn't available," recalls Woolrich. AMI developed a chronic pain group which Woolrich is running.
10.
Comments & reflections on piloting a whole system of patient-focused care
The AMI program, with its client focus, may be viewed as raising a fundamental
question for a pilot project: Given the variability, can we still make a
judgment about the clinical and cost outcomes of the project?
Richard Sarnat, MD, AMI co-founder
The variability is significant. First, patient care has a range of inputs.
These can include CD's, massages and/or acupuncture treatments, the counsel of
a caring holistic nurse, conventional services, mind-body CDs, chiropractic,
community support groups, educational materials and home visits. In addition,
AMI's apparent willingness to re-invent aspects of its program to meet client
needs adds to the complexity. In short, a researcher trained only to examine
single agents in placebo-controlled trials would probably break out in hives
upon looking at this pilot, if not end up with a frank case of the
heebie-jeebies.
But can we make a judgment about the value of the pilot?
A researcher trained only to examine
single agents in placebo- controlled trials would probably break out in hives
upon looking at this pilot, if not end up with a frank case of the
heebie-jeebies.
The integrative community
needs
to develop its ability
to examine the effectiveness
and cost-effectiveness of
this kind of health care
I put this to Richard Sarnat, MD, AMI's co-founder. Sarnat says he
believes the answer is yes and no. No, he says, because every personalized
variable is not included and accounted for within the research design. There is
"background activity" not captured. But yes, Sarnat asserts, because
the charge from the state of Florida was to pilot a program which could improve
clinical outcomes and create a global reduction in the costs associated with
these populations. As was referenced in Part #1 of this series, and will be
explored more deeply in Part #3 (clinical outcomes) and Part #4 (cost
outcomes), AMI has not only been gathering useful outcomes. AMI’s performance
led the state to expand and extend the program.
I look at the AMI model and think how familiar I am with this combination of
diversity of inputs, individualization of care and shifting of treatment
protocols. All three components characterize the care a person can be expected
to receive in any self-respecting integrative medicine clinic or from any whole
person-oriented practitioner, whether that person be an integrative/holistic
medical doctor, naturopathic physician, broad-scope chiropractor or general
practitioner of traditional Chinese medicine. The integrative community needs
to develop its ability to examine the effectiveness and cost-effectiveness of
this kind of health care in community settings. (See related Integrator article.) The AMI project happens to be a pilot
for all of us.
For her part, Woolrich is content with the
results: "We know from our surveys and analysis that patients like the
care. They feel it's helping them. They have fewer ER visits. They are
going to their primary care providers less. And they're taking less medication."
What is also clearly true is that the delivery of these services to these
patients is also creating a new level of job satisfaction in their case
manager.
__________________
Next:
Part 3: The Experience of Patients and Practitioners Part 4: TheDebate over the Cost Savings Part 5: Community Health Leaders Respond to the Pilot
* Woolrich called the educational training in holistic care a quality educational progam offered in Florida which was not, however, able to sustain itself.
Disclosure: As noted, AMI is an Integrator sponsor.
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