This poster presentation will demonstrate how utilizing geographic territories and member volumes assigned to Medical Homes, the Texas Children’s Health Plan initiated a team approach to supporting patients and providers. Case Managers, Provider Relations Managers, and Resource Coordinators focus on unique population needs using identifiers of claim information, community assessment data, and provider referral.

Seventeen distinct territories were mapped and analyzed for health service locations, service sites, chronic diagnoses, inpatient trends, preventive care delivery rates, and emergency room encounters.

The goals of improved access for patients, improved member outreach, increased preventive use, increased compliance with chronic care plans, and decreased emergency room patterns were approached through targeted, parallel communication campaigns aimed at providers and patients understanding and support of the Medical Home.

Providing Medical Homes with monthly disease registries, creating personalized picture postcards requesting patients to call for appointments, discussing the top ten high-use patients in each practice, and bringing case managers and specialist physicians to the Medical Homes for conferencing were all strategies employed to make a difference in this primarily pediatric Medicaid population of 220,000.

Initiating member outreach emphasizing self-care strategies, education, care planning, and resource needs were conducted with a case management approach, using local resources and supporting the Medical Home as a central point of health information and consistency of care delivery. Included in this endeavor was a collaborative program development component which involved patient families, as well as school and health care representatives to refine programs to truly meet the needs of members.

When combined with community outreach measures delivered by case managers and the provider relations team in the schools, parks, and apartment complexes of the area, we have a result of positive impact on high-cost service utilization and increased access (hours open for care) for patients in this vulnerable population.