Economic barriers, cultural and/or linguistic access barriers to primary medical care services and a growing number of un- and underinsured are swelling the ranks of the medically underserved.

Successful and ongoing delivery of healthcare to these individuals can be hindered by their outdated contact information, chronic disease exacerbated by mental illness and frequently transient nature.

However, many organizations are rising to these challenges, employing novel methods to make contact with Medicaid and Medicare beneficiaries, the categorically needy and others and engage them in successful disease management (DM) programs.

Their success stories, suggestions and lessons learned are contained in this 46-page special report, "Delivering Disease Management to Medically Underserved Populations Plus 21 Strategies for Making and Keeping Contact with Hard-to-Reach Clients."

Against a backdrop of DM initiatives for the medically underserved in place at APS Healthcare, Vermont Health Access and Horizon NJ Health, there are also 21 concrete strategies for the identification and engagement of elusive clients and patients.

Contributing authors include Philip M. Bonaparte, M.D., chief medical officer with Horizon NJ Health; David Hunsaker, president of public programs with APS Healthcare; Caryn Jacobi, R.N., associate vice president of operations for Illinois, McKesson Health Solutions; and Elizabeth Reardon, M.P.H., managed care director of Vermont Health Access. They share real-life case studies to illustrate how out-of-the-box thinking, community collaborations, and multi-channel approaches to client identification are yielding positive results in health outcomes and cost containment.

Additionally, HIN's 2007 non-scientific online survey on this topic yielded further contact strategies from more than 65 healthcare organizations. This report includes a summary of their suggestions for preventing medical complications and improving the overall health of medically underserved patients, members and clients.

You'll get details on:

• Redefining DM for transient, hard-to-reach populations;
• Improving program success with community, agency and provider partnerships;
• Reducing unnecessary and repeat emergency room visits via case management;
• Factoring behavioral health issues into the care plan;
• Assessing clients' "readiness to change" and tips to encourage behavior modification and self-management;
• Tapping technology and data mining to correct inaccurate or outdated contact information;
• Launching disease-specific initiatives targeted to this population;
• Implementing staffing, training and processes for optimal DM delivery; PLUS
• 21 proven strategies from Horizon NJ Health and McKesson Health Solutions for connecting with elusive clients.

Table of Contents

• Understanding Disease Management at Horizon NJ Health
  • Administering DM Programs for the Medicaid Population
  • Components of DM
  • ER Claims Analysis
  • Asthma & Diabetes DM
• The Vermont Medical Home: Integrating Behavioral Health and Primary Care
  • Mental Illness, Morbidity and Mortality
  • Patient Involvement
  • Key Concepts
  • Care Partner Nurses
  • Changes and Recommendations
• APS Healthcare DM Programs Target Medicaid
  • Patient Identification
  • The Cost of Bad Care: High Variances and Disparities
  • Advancing Interventions Based on Treatment Gaps
  • Urban Myths: Frontier, Rural and City
  • Return on Investment
• 21 Strategies to Identify and Engage Hard-to-Reach Clients
• HIN Survey Results: How Healthcare Organizations Locate and Communicate with Hard-to-Reach DM Clients
  • Solving the Problem of Hard-to-Reach Patients
  • Successful Strategies
  • Developing Trends
• Q&A: Ask the Experts
  • Creative Care
  • Identifying Undiagnosed Diseases with DM
  • Electronic Healthcare
  • Physician Feedback
• Glossary
• For More Information
• About the Authors