Transcript NAVIGATING THE SPECIAL NEEDS UNIT - abin

Traumatic Brain Injury
Advisor Board
Presentation:
Case Management within
PA Medicaid
September 04, 2008
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PA Mandatory Managed Care
Medicaid Program (HealthChoices)
AND THE SPECIAL NEEDS UNITS
Eric D. Ulsh
Human Services Program Specialist
Department of Public Welfare
Office of Medical Assistance
Bureau of Managed Care Operations
Division of Quality and Special Needs
Coordination
2
Main Components
Physical
Health
Program
HealthChoices
Behavioral
Health
Program
Enrollment
Assistance Program
3
Where are we now?
SW: 1999
L/C: 2002
SE: 1997
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Physical Health
Choice of Physical Health Plans
Choices of doctor (PCP = Primary Care
Physician or Practitioner)
Same service coverage as available under
MA FFS Program. (Based on Category of
Assistance)
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Physical Health Services
Outpatient Hospital
Inpatient Hospital
Dental, Vision
Physician Services (including OB/GYN)
Medical Equipment
Diagnostic Services
Home Health
Prescriptions
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MEMBER SERVICES
• Member handbook includes information on:
-Services
-Special Needs Units
-Transportation
-Complaints/Grievances/Appeals
• Member hotline
• Member education and outreach
• Coordination of care
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HealthChoices Offers Help to
Overcome Obstacles
Member Services Department
Special Needs Unit
•PH Plans
•Department
•EAP
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HEALTHCHOICES PHYSICAL HEALTH PLANS
Southeast
AmeriChoice Health Plan
Health Partners Health Plan
Keystone Mercy Health Plan
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HEALTHCHOICES PHYSICAL HEALTH PLANS
Southwest
UPMC for You Health Plan
Gateway Health Plan
Unison Health Plan
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HEALTHCHOICES PHYSICAL
HEALTH PLANS
Lehigh Capitol
AmeriHealth Mercy Health Plan
Gateway Health Plan
Unison Health Plan
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HealthChoices Program Design
Inclusion of persons with special needs
Created Special Needs Component
Enrollment Assistance Program (EAP) for
enrollment and Managed Care Organization
(Plan) changes
Each Physical Health - Managed Care
Organization (PH-MCO)
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SPECIAL NEEDS UNITS
Each Physical Health Managed Care
Organization (PH-MCO) has one
Special Needs Unit Coordinator/Director
Has direct contact with the Medical Director
at the PH-MCO
Qualifications include multiple years
experience with Special Needs Populations
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DEFINITION OF A SPECIAL NEED
* non-categorical
Anyone who thinks they have a special need
can be referred to the special needs unit
Examples of a special need:
Short term
HIV/AIDS
Long term
Brain Injury
Mental Retardation Social Issues
Pregnant Women
Behavioral Health Coordination
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COORDINATION OF CARE
PCP
Advocate
Family Member
HEALTH PLAN (MCO)
SPECIAL NEEDS UNIT
Community Agency
Community Service
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SPECIAL NEEDS UNITS
ASSIST MEMBERS:
Navigate the Physical Health
Managed Care Organization
(PH-MCO)
Access Care Coordination
Access Timely & Effective Services
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SPECIAL NEEDS UNITS
HELP THE MEMBER TO:
Assist in selection of a Primary Care
Physician (PCP)
Assist in identifying non-MA Resources
Assist with complaint and grievance
procedure
Transition to Waiver services
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SPECIAL NEEDS COORDINATION (Examples)
Behavioral Health MCOs
Other Physical Health MCOs
Medical Assistance Transportation Program
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SPECIAL NEEDS COORDINATION (Examples)
Community Based Agencies
Public Health Departments
Consumer Advocacy Groups
Home and Community Based
Services Waivers
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Special Needs Coordination
(internally within PH-MCO)
UM/QM
Member Services
Provider Relations
Pharmacy Services
Disease Management
20
Special Needs Coordination
(external)
DPW’s Special Needs Division
Other PH-MCO Special Needs Units
Other state, county and local agencies
Waiver Providers
Community Resources
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EXAMPLES OF SNU ACTIVITIES
Home Visits
Specialist as PCP Requests
Individual Case “Interagency” Meetings
including IEP development participation
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EXAMPLES OF SNU ACTIVITIES (CONT.)
3-Way calls with PCP
Coordinate with ancillary providers
Assist with obtaining referrals –
medical, legal, other
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HOW SPECIAL NEEDS UNITS MAKE A
DIFFERENCE
ONE PERSON AT A TIME
Each special needs member’s coordination
needs and challenges are unique and
deserve the individualized attention
necessary to get those needs met
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SND/COMMCARE Coordination Process
Identify COMMCARE Member to PH-MCO
Identify Service Coordinator to PH-MCO
SNUC outreaches and establishes
communication link with Service Coordinator
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SND/COMMCARE Coordination
Objectives
Prevent duplication of services
Serve as a resource for resolution
of PH service concerns
Assist in coordination with BH-MCO
Identify other community resources
for necessary services not covered
under the State plan or the
COMMCARE Waiver
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SNU COORDINATORS
Southeast
Southwest
Lehigh/Capital
AmeriChoice
Sarah T. Morvin
1-800-832-4571
Gateway
Jeanine Kilgore
1-800-642-3550
Gateway Jeanine
Kilgore
1-800-642-3550
Health Partners
Shelly Stevens
1-800-553-0784
Unison
Demetrios C. Marousis
1-877-844-8844
Unison
Demetrios C. Marousis
1-877-844-8844
Keystone Mercy
Veronica Medina
1-800-521-6860
UPMC for You
Christina Salopek
1-800-286-4242
AmeriHealth Mercy
Jared Young
1-888-991-7200
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Southeast Telephone Numbers
Member Services
AmeriChoice
1-800-321-4462
TTY 1-800-654-5984
Health Partners
1-800-553-0784
TTY 215-849-1579
Keystone Mercy
1-800-521-6860
TTY 1-800-684-5505
Special Needs Units
AmeriChoice
215-832-4571
TTY 1-800-654-5984
Health Partners
215-991-4370
TTY 215-849-1579
Keystone Mercy
1-800-521-6860
TTY 1-800-684-5505
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Southwest Telephone Numbers
Member Services
Special Needs Units
UPMC for You, Inc.
UPMC for You, Inc.
1-800-286-4242
TTY 1-800-361-2629
1-800-286-4242
TTY 1-800-361-2629
Gateway Health Plan
Gateway Health Plan
1-800-392-1147
TTY 1-800-654-5988
1-800-642-3550
TTY 1-800-654-5988
Unison
Unison
1-800-414-9025
TTY 1-888-616-0071
1-877-844-8844
TTY 1-800-473-0989
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Lehigh Capital Telephone Numbers
Member Services
Special Needs Units
AmeriHealth Mercy
AmeriHealth Mercy
1-888-991-7200
TTY 1-888-987-5704
1-888-991-7200
TTY 1-888-987-5704
Gateway
Gateway
1-800-392-1147
TTY 1-800-654-5988
1-800-642-3550
TTY 1-800-654-5988
Unison
Unison
1-800-414-9025
TTY 1-888-616-0021
1-877-844-8844
TTY 1-888-616-0021
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RESOURCES
Department of Public Welfare
website:
www.dpw.state.pa.us
Phone Us
Managed Care Operations,
Special Needs Division
717-705-8220
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PA Bureau of Fee for Service Programs
Access Plus-
Pennsylvania’s Enhanced Primary
Care Case Management (EPCCM) program that
operates in the 42 counties where HealthChoices is
not operational by the Department of Public Welfare
Jean Whitehead, RN,CCM
Clinical management Consultant
Department of Public Welfare
Office of Medical Assistance
Programs
Bureau of Fee for Service
Programs
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Components of ACCESS Plus
Physical Health Services – provided, coordinated and managed by
PCPs.
Intense Medical Case Management- provided by Department of Public
Welfare
Disease Management Services – provided by the ACCESS Plus
contractor and includes the following conditions:
Asthma
Diabetes
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Congestive Heart Failure
Care Coordination Services – provided by the ACCESS Plus contractor
Enrollment Assistance Services – provided by the Enrollment
Assistance Program contractor
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ACCESS Plus Service areas
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CASE MANAGEMENT MODEL
Community
assessment
advocacy
Recipient
&
Care manager
planning
facilitation
Payer
Healthcare
team
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OVERVIEW
UNIT STRUCTURE
27 nurse case managers (17 general, 6 high risk OB, 2 high risk
neonate,1 behavioral health care liaison, 1 supervisor)
Nurse case managers: generalists & specialists, provide medical
care management services to all age groups & medical
diagnoses
Model: telephonic medical case management; in-home visits
made on a case by case basis
Referral sources: medical directors, prior authorization unit,
inpatient & special procedure unit, pharmacy unit, McKesson
disease case managers, AHS care coordinators, legislative
affairs, legal affairs, secretary & deputy secretary's office,
physicians, Predictive Modeling, others
Referrals are submitted to a designated care manager for initial
review and assigned as appropriate
Case manager assigned performs a comprehensive assessment
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OBJECTIVES OF CASE MANAGEMENT UNIT
Provide care management services, assuring continuity of care
and follow up
Provide comprehensive assessment of medical, social and
psychosocial needs
Develop of plan of care addressing clinical care/services, social
and psychosocial needs
Provide assistance in coordinating multidisciplinary health care
services and referral activities, to minimize duplication of
services
Provide ongoing follow-up activities to ensure delivery of
needed health care and social services
Provide periodic reassessment and evaluation of recipient needs
and care management activities
Collaborate with physicians, specialists and other medical
professionals to meet the recipient’s needs
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CRITERIA FOR
CASE MANAGEMENT INTERVENTION
(potential candidates)
Amputations (post-op, rehab phase & new prosthesis)
Burns
Complex medical/surgical issues
Complex wound care
Congenital anomalies (care required during the first 12 months)
Coordination of care
DME/ med supply issues
High profile issues (Governor’s, Deputy Secretary ‘s and/or legislative affairs office)
High risk maternity management
High risk mental health with physical health co morbidities
High risk neonates
High utilization of home health services
HIV/AIDS
Multiple in-patient admissions (four (4) within a six (6) month period)
Out of State services/ placement
Poor prognosis (6-12 months) with potential end of life planning needs/Hospice
Pain Management
Residential treatment facility monitoring
Spinal cord injury
Transplant candidates, organ
Traumatic brain injury
Vent/tech dependent
Other referrals, as appropriate
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CASE MANAGEMENT PROCESS
FLOW CHART/WORKSHEET
REFERRAL
TRIAGE FOR POTENTIAL
CM INTERVENTION
APPROPRIATE REFERRAL
ASSIGN TO CM
INAPPROPRIATE REFERRAL
DENY
ASSIGNED CM
MAKES OUTREACH CALL TO RECIPIENT
COMPLETES INITIAL INTERVIEW & ASSESSMENT
PLANNING
Establish individualized care plan
Implementation
Intervention
Coordination
Monitoring
Evaluation
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Contact Information
Intense Medical Case Management Unit
Jean Whitehead
717-772-6777
Mallie Carter
717-772-6782
Joanne MacCollum or Nancy Snyder
717-772-6048
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Any Questions
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THANK YOU!
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