Team effort keeps members independent

Team effort keeps members independent

Project integrates Medicare, Medicaid benefits

A demonstration project that integrates Medicare and Medicaid benefits for Massachusetts residents who qualify for both programs is helping participants get all the services they need to remain independent, says Helene S. Forte, RN, MS, PHM, vice president for care management for Network Health.

The Commonwealth of Massachusetts selected Medford, MA-based Network Health, a division of Tufts Health Plan, as one of three managed health plans participating in the Massachusetts One Care demonstration project to administer the services. Network Health provides health care coverage to Massachusetts residents with disabilities and low or moderate incomes.

The members in the One Care demonstration project are ages 21 to 64, are enrolled in Medicaid, and have a disabling condition that makes them eligible for Medicare, Forte says. People in the program have significant chronic physical and mental health issues. Some struggle with substance abuse, are homeless, and have major social needs.

"These members receive fragmented care. A lot of time, they see multiple providers with no one to look at them holistically and make sure the services are coordinated. They have trouble navigating the healthcare system, and often they don’t realize some of the benefits they are eligible for," Forte says.

The purpose of the demonstration program is to coordinate all of the services and resources the individuals need and help them be as independent as possible, she says.

When participants are identified for the program, the state notifies them of their eligibility and sends them a packet explaining the One Care program. When members enroll, Network Health sends them information specific to their plan, called Network Health Unify. Then the Network Health outreach staff calls the individuals, explains the program, determines if they have immediate needs, and schedules an assessment by a clinician. The assessment may be at the member’s home, a community center, or a provider office — wherever the person feels most comfortable, Forte says.

A care manager, either an RN, a licensed mental health professional, or a social worker, is assigned to the member based on the initial information Network Health has received about the member. If the member’s needs appear to be mostly medical, an RN case manager conducts the assessment. If they primarily have behavioral health issues, a mental health professional or social worker is assigned, she says.

After the assessment is completed, a multidisciplinary team meets to develop a plan to coordinate the care and meet the member’s needs. Services are tailored to meet each individual’s needs.

The Network Health members of the team include the RN care manager, the behavioral health care manager, the social work care manager, the community outreach staff, the medical director, and pharmacist.

If the member is already receiving other services, representatives from those organizations are included on the team. For instance, the Visiting Nurse Agency case manager would attend if the member is receiving home health services. If the member is receiving Long Term Services and Support (LTSS), the person who oversees the coordination of services would attend. The member and family members or caregivers are also part of the team. Some of the team members attend in person, but most attend by conference call, Forte says.

The care manager shares the information from the assessment, including the members’ needs and challenges. Using that information, the team works with the member and family members to develop a plan of care and goals for the member, she says.

"The team pulls all the pieces together by identifying all the members’ needs and setting in motion ways for the member to access all the components of care. The care manager follows up with all the disciplines involved and works with the members on an ongoing basis to make sure all the needs and goals are being met," Forte says. The care managers follow up with the members as frequently as necessary until they become more self-sufficient, then taper off but continue to follow them.

After the care plan is in place, the team members continue to meet as needed to monitor progress and make changes in the plan when necessary. "These members have very complex needs, and we expect that things will change. We may need to pull the team together periodically when the members’ care needs escalate or there is another change," Forte says.

To keep everyone on the same page, Network Health has set up a centralized record system with information on all enrollees. The member controls which team members can have access to sensitive information. The interdisciplinary team can access the records and add documentation and all providers have access to the information so they know what services and supports the member is receiving, Forte says.

Often during their meetings, the multidisciplinary team can uncover problems that have frustrated the members and work to solve them so the members will have what they need to become more independent, Forte says.

A case in point is a 58-year-old woman with medical and behavioral health issues. Her physical disability impacted her mobility and her ability for self-care. She had been unsuccessful in getting her physician to understand her need for a motorized wheelchair to help her become more independent. "She had been seeing the same primary care provider for 18 years but didn’t feel like he was hearing her," Forte says.

The care manager listened to her concerns and gave her tips on communicating with her providers, she says. When the multidisciplinary team discussed the case, they made sure the woman’s physician was present.

As a result of the meeting, the Network Health and Long-Term Services and Support team worked with Easter Seals to get the woman the equipment she needed, Forte says.

"The member told us that this was the first time she felt like her physician had listened to her. The new equipment made her more independent and she was feeling less stress. By partnering with the member, we were able to help her deal with her issues and become more involved in caring for herself," Forte says.

Network Health has developed a community advisory council, comprised of members in the program, which meets quarterly to share their experiences. Council members give the health plan input on what parts of the program are working well and have identified areas of improvement. "We’ve had three meetings, all of which were very interactive. They have given the care managers a lot of accolades and given us good information. It’s working very well," says Kathleen Connolly, vice president of sales, marketing and products, and executive director of the Network Health Unify plan. "As confirmed by the members themselves, the goal of One Care to provide seamless care management program for our members seems to be on track," she says.