Medicaid Managed Care: Rochester, NY

Monroe Plan groupMonroe Plan & ViaHealth Partnership

Overcoming Obstacles
to Care

Like many cities, Rochester, N.Y., has long faced challenges in children’s health care. A 1998 study ranked the area near the bottom of 216 cities in child quality of life. The city’s school district has the state’s highest poverty rate (78%) and a large minority population.

In light of such challenges, the success of Monroe Plan’s program to improve asthma care for children seems even more remarkable. Partnering with ViaHealth in the fall of 2000, Monroe Plan launched a pilot program to shift asthma care away from emergency services and inpatient care to collaborative self-management of the disease.

“Once you have a sizable chunk of the population tuned into asthma, fewer resources are required to maintain good results,” says Joseph Stankaitis, M.D., chief medical officer of Monroe Plan for Medical Care. “As asthma patients get engaged and educated and the providers get onboard, it leads to long-term success.”

Communicating with Patients—and Providers

While the pilot program was well-constructed, program managers determined that two critical factors—outreach and engagement of patients—needed more attention and resources. In October 2001, the Monroe Plan-ViaHealth Partnership expanded its focus in those two key areas with support from the Robert Wood Johnson Foundation. It made a huge difference.

Reaching patients by mail and phone, and in turn prompting them to visit asthma centers, had been difficult in the pilot program. The new process emphasized face-to-face contact as well as consistent follow-ups with patients and providers throughout the program.

Once families were contacted, outreach workers visited patients’ homes to build rapport, explain the program’s services and benefits, and provide information and asthma resource materials in English and Spanish. During this initial visit, asthma center appointments were scheduled for the children, a brief patient history was obtained, and transportation arrangements were made as needed (bus tokens or cab service).

The appointments with the certified asthma educator usually fell within two weeks of the home visit—much quicker than the typical four- to eight-week wait for specialist physician appointments. Each initial visit consisted of an evaluation, spirometry, basic asthma education and the introduction of an asthma action plan. The next visit included allergy skin testing and ongoing asthma education. Follow-up visits were scheduled every six months for the next two years and after any hospitalization or emergency department visits. To reduce missed visits, staff made reminder calls to families the day before. If appointments were missed, staff diligently followed up to reschedule them.

Program staff also kept providers fully informed and educated, starting with a letter to each patient’s primary care provider (PCP) about participation. Asthma center specialists sent these PCPs updates after every contact, from the initial home visit to education sessions and follow-ups, and after missed appointments. PCPs were also notified if patients visited the emergency department. Additional coordination with providers included specialist-led on-site education sessions covering standardized asthma evaluation forms and action plans, inhaler techniques and case study presentations. To facilitate quick consultations, each PCP office had a specialist designated as a primary contact.


The program demonstrated several positive outcomes by the end of the funding period in 2004. The number of patients in the moderate-to-severe asthma category declined from 51 percent to 26 percent. And while specialty services increased for patients in that category from 8 percent to 39 percent, the increased costs of those services were offset by sizable decreases in emergency department visits and hospitalization.

As a result, Monroe Plan decided to sustain and expand the program after support from the Robert Wood Johnson Foundation ended. Today, with a few significant additions such as an incentive for reimbursing providers for patient education sessions, the program model has been expanded to the Monroe Plan for Medical Care’s full service area of about 2,500 children.

“The program has developed a greater understanding of asthma management on both the provider and patient sides,” says Dr. Stankaitis. “That’s extremely valuable because, with our expansion, we’ve been able to provide more services with the same number of staff.”


Recognizing that the success of educating asthma patients in self-care relies heavily on communication, the Monroe Plan uses outreach workers to keep participants tightly connected to asthma center specialists and primary care providers. The program also works to educate those providers and their staffs about best practices and resources for asthma treatment.

The Monroe Plan for Medical Care and ViaHealth partnered to develop this program. The Rochester-based plans targeted high-risk children enrolled in Medicaid and State Children's Health Insurance Programs (SCHIP) under managed care. Treatment was conducted at several locations, including four Community Health Centers, two pediatric practices and three school-based health centers.

Strategies and Programs

  • Implemented a communication-intensive process for treating patients, including:
    • Appointments for participants with asthma center specialists; and
    • Reminder calls and transportation assistance to appointments.
  • First visit to the center included evaluation, spirometry, education and development of an asthma action plan.
  • Second visit included allergy skin testing and ongoing asthma education.
  • Contacted the patient’s family four to six weeks after the second visit to review needs and reaffirm adherence to treatment.
  • Scheduled follow-up visits every six months for two years and after any emergency room visits or hospitalization.
  • Followed up and rescheduled missed appointments and implemented interventions.
  • Kept the pediatric patient's primary care physician updated on the specialty visits.
  • Conducted home visits to assess environmental conditions.
  • Provided asthma education for physicians and support staff at health centers.
  • Took part in school health fairs and other public events to raise asthma awareness in the community.

Children and Families Served

  • 418 Monroe Plan enrollees under age 19 were eligible for expanded pediatric asthma management services.
  • 40 percent of these enrollees were recruited via phone calls, mail and home visits.


  • The number of moderate-to-severe asthma patients receiving asthma specialty services increased from 8 percent to 39 percent through the program.
  • The percentage of participants categorized as moderate-to-severe asthmatics declined from 51 percent to 26 percent by the program’s conclusion.
  • A series of four quality-of-life surveys administered in 2003 and 2004 to the families of children participating in the program showed improvements in areas such as daytime symptoms, nighttime symptoms and functional limitations.
  • Based on its success, the program model has been expanded to the Monroe Plan for Medical Care’s full service area of about 2,500 children.


  • Total asthma-specific costs were $29.78 per patient per month.
  • While costs for asthma specialty services rose, decreases in emergency room and hospitalization costs offset the increases.
  • After pilot grant support, Monroe Plan sustained and expanded the program.

Lessons Learned

Effective outreach and patient engagement are vital to the success of programs like Monroe Plan. In this case, it involved a comprehensive approach that included home visits, ongoing follow-ups and appointment notifications, facilitating transportation to appointments, and the use of quality-of-life surveys.