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The Care Management Program with Wyoming Medicaid
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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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.
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:
- 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
- Identified clients with frequent readmissions (identified from claims analysis) are contacted by a WYhealth care manager to engage these clients in care management
- Recruitment of facility(s) to participate in a readmission pilot