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The Care Management Program with Wyoming Medicaid

Pay 4 Participation

The Pay-for-Participation (P4P) program allows Medicaid primary care providers to receive additional reimbursements for:

  • Providing health education to their Medicaid clients with chronic illnesses
  • Referring their clients into the Wyoming Healthy Together Health
  • Management program

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Diabetes Initiative

At no cost to you or your patients, your Medicaid patients receive support through case management by a licensed clinician that provides self management skills.  Care managers can refer your patients to community resources.  Providers receive Pay 4 Participation incentive for clinical training.

Guidelines for Diabetes Management:

At each regular diabetes visit:

  • Measure weight & blood pressure
  • Inspect feet if one or more high-risk foot conditions are present
  • Review self-monitoring glucose record
  • Review/adjust medications to control glucose, blood pressure, and lipids.  Consider low-does aspirin for CVD prevention
  • Review self-management skills, dietary needs, and physical activity
  • Assess for depression or other mood disorder
  • Counsel on smoking cessation and alcohol use

At each quarterly diabetes visit:

At each annual diabetes visit:

  • Obtain fasting lipid profile
  • Obtain serum creatinine
  • Perform urine test
  • Refer for dilated eye exam
  • Perform comprehensive foot exam
  • Refer for dental/oral exam
  • Administer influenza vaccination
  • Review need for other preventive care or treatment

Medicaid Members may be able to enroll in the Choice Rewards diabetes incentive program.

ER Utilization

WYhealth activities to address ER utilization include:

  • 24/7 Nurse Advice line
  • Identification and outreach to engage frequent ER users in care management
  • Information and outreach to providers and facilities to encourage referral to WYhealth care management
  • Collaboration with pilot facilities to receive daily or weekly Medicaid ER visit census reports

Activities to address readmissions include:

  1. Using hospital census reports, submitted weekly to WYhealth, Medicaid clients discharged from the hospital are called by a WYhealth care manager upon discharge, to inquire about appropriate outpatient follow-up, screen for appropriate care management and educate on self-management and recovery action plans
  2. Identified clients with frequent readmissions (identified from claims analysis) are contacted by a WYhealth care manager to engage these clients in care management
  3. Recruitment of facility(s) to participate in a readmission pilot

Discharge flyers can be provided to your Medicaid patients:    Newborn      Youth       Adult

Total Health Record (THR) 
​ The Total Health Record (THR) for Wyoming Medicaid consists of a health information exchange (HIE) between designated data sources and electronic health record systems within the State of Wyoming, a web-based Electronic Health Record for use by providers which has been certified by the Office of the National Coordinator, and a Patient Health Portal, for use by patients.  The THR was developed to improve the coordination of care within Wyoming Medicaid’s health care delivery system and provide the capability for patients to access a robust, consumer-directed module via patient portal.  The THR gives clients and the entire provider team access to a broad range of intelligent data regarding the client’s health conditions, meaningful prevention and maintenance information and access to other healthcare professionals.