CMs help multiple providers communicate
Executive Summary
UCare’s care coordinators are the hub for communication among providers treating the Minneapolis health plan’s dual eligible members enrolled in one of two care plans depending on their age.
• Most care coordinators live in the same community as the members with whom they work so they are familiar with the resources in that community.
• Members who are over 65 are assigned a case manager who conducts a face-to-face assessment of medical, behavioral health, and social needs and follows up with them at regular intervals.
• Younger members, who are part of UCare’s special needs program for adults with disabilities who qualify for Medicaid, tend to be more independent and many prefer to manage their own care.
Coordination varies by member needs
UCare members who are eligible for both Medicare and Medicaid are enrolled in one of two different programs, depending on their age.
Members who are dual eligible and over age 65 are covered by the Minnesota Department of Human Services’ Minnesota Senior Health Options program. UCare care coordinators manage the integration of both the Medicaid and Medicare benefits for this senior population.
Individuals ages 18 to 64 who have been certified as disabled and meet certain financial requirements may enroll in UCare Connect, a special needs program that offers healthcare coverage for adults with disabilities who qualify for Medicaid. About half of the members in UCare’s plan also qualify for Medicare.
UCare manages the Medicaid benefits for the younger UCare Connect members and helps those members eligible for Medicare access those benefits, says Jeri Peters, RN, BSN, UCare’s vice president and chief nursing officer.
The care coordinators are the hub for communication among the multiple providers who treat dual eligible members. "They ensure that everyone on the interdisciplinary team who is treating the member is aware of the comprehensive plan of care, including interventions and services other providers have developed and the medications they have prescribed. This helps eliminate duplication of services and keeps all the providers on the same track," Peters says.
Many of the dual eligible members have behavioral health issues along with physical issues and chronic conditions. A large percentage of them also need assistance with housing, meals, transportation, and support in the community.
Generally, UCare care coordinators live in the same community as the members they work with and are familiar with the resources that are available within the members’ communities, Peters says.
"We believe care coordination is best done at the local level and contract with local entities, such as counties, local agencies and care systems in areas throughout Minnesota where we do not have our own case management staff. Regardless of whether they are our own employees or delegates working on our behalf, the care coordinators follow all of UCare’s procedures for elderly and disabled members," Peters says.
UCare has different care models for the dual eligible populations, based on several factors including population analysis, demographics, and contractual obligations with payers and regulators. UCare assigns a care manager to members who are 65 and older. Within 10 days after enrollment, a care coordinator contacts them and sets up an appointment to visit them in their home and perform a health risk assessment that includes an assessment of their medical, behavioral health, and social needs.
A care coordinator conducts a face-to-face health risk assessment and identifies gaps in care and services that the individual needs, Peters says. The members often need medical and behavioral healthcare services and have multiple social needs.
The care coordinators develop an individualized care plan that addresses gaps in care and social needs, and work with the members to set mutual goals and identify services and interventions for meeting them. Then they work with the member to establish goals and strategies for meeting them. If members do not have a primary care provider, the coordinators help them identify one and can assist them in scheduling appointments.
"The care coordinators look at the full range of services — medical, behavioral, and long-term services — to fill each individual’s needs and facilitates access to the services through the interdisciplinary care team. The primary care provider is always part of the team. Other clinicians and providers join the team as members need services," she says.
During the home visit, the care coordinators ask the members to show them all the medications they take, along with vitamins and supplements, Peters says. They review the medication and make a list of everything the members are taking and forward it to a UCare pharmacist for review. If there are duplications or other concerns with the medication, the pharmacist contacts the prescriber, she says.
The care coordinators at UCare help members get connected to nutritional programs like food stamps, food banks, or local farmers markets. They arrange transportation to medical appointments, day treatment programs, and in some cases, social activities such as senior day treatment. They help them find affordable housing that is safe and sanitary. They can help seniors find someone to perform repairs, help with housekeeping, and prepare food, Peters says.
The care coordinators stay in touch with the senior members regularly for a minimum of six months, contacting them as frequently as needed and tapering off the visits as the members become more self-sufficient, she says. They conduct a full reassessment and review the plan of care each year.
The care coordinators fax a copy of each member’s plan to the primary care provider and communicate with the entire disciplinary team as needed, Peters says.
UCare care coordinators offer all disabled members a face-to-face assessment and about 50% to 60% take advantage of the offer. Dual eligible members under age 65 are eager to self-manage their conditions and maintain independence, Peters points out.
"Many are doing a good job of self-managing and they don’t need our assistance. Our care coordinators educate the members on the need for preventive care screenings and identify gaps in services the younger dual eligible members need. The care coordinators always offer to facilitate access to services and help make appointments while remaining sensitive to the fact that many members prefer to make arrangements themselves," she says.
