Continuing changes in the health care system have prompted states to alter their approach to the delivery of services to low-income families. Burgeoning Medicaid budgets have literally mandated that Program administrators implement policies and practices that have the potential for realizing long range cost savings. Cost saving is a critical factor, but assuring that the families being served actually have access to the services is as important. To address these needs, many states have turned to Primary Care Case Management.

In 1993, this was the route the Pennsylvania Department of Public Welfare chose to take when they applied for, and received, a Federal waiver to develop and administer a Primary Care Case Management program. Because of our association with EPSDT in Pennsylvania over the 13 previous years, AHS was chosen to administer this new endeavor called the Family Care Network (FCN). Moving into the managed care arena was a logical step for the company. The infrastructure for developing such a program was already in place, and our years of experience in managing other large-scale programs more than adequately prepared us for the task at hand.

Essential components for the implementation of a successful PCCM Program included:

• Provider Enrollment. For AHS, this meant increasing the number of providers beyond those currently serving in the EPSDT Program (being an EPSDT provider is a prerequisite for enrollment in FCN). Using the experience we have gained over the years in recruiting providers for various programs, we were extremely successful in securing the additional participation needed. Prior to the implementation date, AHS had garnered commitments from local providers to serve consumers, and we had more than doubled the number of providers who actively participated in the EPSDT Program.
  
  back to top
  
• Consumer Enrollment. While recruiting and maintaining an adequate provider base is critical for the success of such programs, an even more important and complex task is to assure that consumers are adequately informed and educated about the Program, appropriately linked with a PCP, and provided with assistance when problems arise. Again, AHS has been able to draw upon its years of experience in providing family focused, culturally sensitive consumer outreach and education activities in a variety of venues. Our goal is to assure that those families enrolled in FCN have as smooth a transition as possible from fee-for-service to what, for most of them, is a totally new way of receiving Medical Assistance benefits.
  
  back to top
  
  
• Member Advocate Unit. As with any large scale program, problems do arise. To address consumer complaints and resolve problems, AHS has established a Member Advocate Unit to assist consumers and providers with difficulties they may encounter. We deal with issues as simple as consumers wishing to change their PCPs, to more complex medical issues for which our Member Advocate Unit staff work in concert with the nurses in our Quality Improvement Department to assure that such problems are dealt with promptly.
  
  back to top
  
  
• Consumer Satisfaction Surveys. Customer satisfaction surveys have been designed to determine consumer satisfaction with their FCN experience and to check on several indicators related to overall Program quality, access and cost. As of the end of December, 2003, we have collected data from over 125,000 surveys. Survey results show that, in terms of the consumer perspective, the FCN Program has been an overall success. Based on the available data, the percentage of respondents choosing the most optimal answer has increased significantly and more or less steadily for all three indices (quality, access, and cost). As this is a source of significant cost savings for the Medical Assistance program, of particular note is consumers' self-assessed inappropriate use of emergency room services, which shows a drop of 49 percentage points since the implementation of FCN.
  
  back to top
  
  

Indicative of our success as the administrator of the Family Care Network, we have:

• outreached an average of 8,500 consumers per week over the phone, and 40,000 per month through the mail;
• discussed impartially with families the relative merits of over 1,400 primary care sites as well as the Network and Medicaid HMOs;
• created an algorithm for automatic assignment that held subsequent consumer changes to 10%, indicating good "matches" between consumers and providers;
• successfully linked over 500,000 Medical Assistance consumers to "medical homes";
• improved access to primary and preventive health services for members; and
• reduced inappropriate emergency department utilization.