Health plan coordinates Medicaid member care
CMs provide long-term coordination
EXECUTIVE SUMMARY
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The Rapid Response Team links members who call to whatever resources they need, whether clinical or non-clinical.
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Complex case managers coordinate care for members with intensive needs and multiple co-morbidities.
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Case managers embedded in medical and mental health clinics assist members and build trust.
Recognizing the problems that Medicaid recipients face and the challenges health plans often encounter in reaching them to coordinate care, Passport Health Plan, with headquarters in Louisville, KY, takes a multi-pronged approach to providing case management for its members.
Case managers on the Rapid Response Team work with members who have short-term needs and need help accessing resources such as transportation and housing assistance, while the health plan's complex case managers provide longer-term care coordination. In addition, Passport has embedded case managers in primary care and behavioral health clinics to provide face-to-face assistance.
"In the past, the case managers mostly worked with members with multiple medical and/or behavioral health issues who required complex care, but we found that our case managers were spending a lot of time with members who had more immediate needs. We found that it was more efficient to have a separate group of case managers work with members who needed assistance for 60 days or less," says Cheri Schanie, RN, BSN, CCM, manager of case management and care coordination.
After a successful pilot project in 2011 in which case managers were embedded in a primary care office and a community mental health clinic, the health plan expanded the program and now case managers meet face to face with Passport members at 33 sites.
"Medicaid members are a vulnerable population and encounter multiple challenges in their everyday life. We are trying to cover as many bases as we can to see that these members get the healthcare services they need," Schanie says.
Passport has publicized its Rapid Response telephone line to members, practitioners, and community advocacy agencies as a way that members can get short-term assistance. "The Rapid Response Team is trained to link members who call to whatever resources they need, whether they are clinical or non-clinical. Sometimes members are doing well except for one issue, such as being out of their medication. Other times, when the case managers talk to them, they determine that the member could benefit from complex case management once the issue is taken care of and makes a referral," Schanie says. For instance, someone who calls the Rapid Response line may need assistance finding a specialist in pain management or may be about to have his or her utilities cut off.
The Rapid Response case managers collaborate with provider offices or community agencies to get the issue resolved. "Our ultimate goal is self management. Often, the members are so overwhelmed that they don't know where to start. We try to get assistance set up, such as arranging for transportation to a doctor's appointment, then educate them on how to do it for themselves," she says.
For instance, a member who needs to take medication for a chronic condition may call after he has taken his last pill and the prescription needs prior authorization. The case manager on the Rapid Response Team would contact the physician and get the prescription filled, and conduct a short assessment while the member is on the phone to determine if he needs to be referred to complex case management.
"We try to get the urgent issues turned around quickly, but we also want to find out if the members need additional support from another case management team," Schanie says.
The complex case management team works with members with intensive needs such as multiple diagnoses and comorbidities. When they receive a referral, the complex case managers conduct an extensive assessment that includes a full medical history, medication review, mental health status assessment including cognitive functioning, substance abuse, ability to perform activities of daily living, caregiver support if any, and cultural or linguistic needs. Working with the member, they develop an individual care plan and set goals that the member agrees to try to reach.
"We also look at barriers to meeting the goals and what Passport benefits or community resources we could access to help meet the goals. When we refer a member to resources, we follow up to make sure they are able to access them," she says.
The case managers follow up with members at intervals determined by the acuity and complexity of the case. Initially, they may call the member every day, then taper off as the member improves.
Passport has disease managers who work with members with chronic conditions including asthma, chronic obstructive pulmonary disease, heart failure, and obesity. They are disease-focused and refer members with comorbidities and complex needs to the complex case managers. The health plan also has case managers who focus strictly on certain complex conditions including HIV/AIDs, sickle cell disease, cancer, transplants, and developmental disabilities.
Embedded case managers meet with Passport members when they see their providers and collaborate with the providers to coordinate care. "They put a face and name to Passport. It's hard to build trust when you're just a voice on the phone. In addition to building trust, having the opportunity to meet with members where they are receiving care decreases the chance for miscommunication or lack of connection. Our goal with this program is to meet as many members as we can to familiarize them with Passport," Schanie says. The embedded case managers in the physician offices make sure all members have had the recommended preventive screenings and help them overcome barriers to following their treatment plan. "They identify gaps in care and help our members access the myriad of programs Passport has to help them improve their quality of life," she says.
The case managers in the mental health clinic are a liaison between the mental health practitioner and the primary care physician.
"Many patients have medical issues that have not been addressed for a long time. The case managers help them make an appointment with their primary care physician and alerts the embedded case manager at the medical office if there is one," she says.
The embedded case manager at a mental health clinic worked with a member with schizophrenia who needed a hernia repair but hadn't seen a medical doctor in years. The case manager set up an appointment with a surgeon, but the patient got tired of waiting and left. She set up another appointment and alerted the embedded case manager at the medical clinic. She sat with the man and kept him occupied until he saw the surgeon.
"The mental health case manager saw him later and he was so grateful to have his problem solved. That's our goal — to assist our members in getting the care they need," Schanie says.
