Download chapter 14 – care coordination - Health Choice Integrated Care

CHAPTER 14 – CARE COORDINATION
14.0 – CASE MANAGEMENT AND DISEASE MANAGEMENT
HCIC’s model of care is designed to provide access to care for members in a holistic approach that
ensures both behavioral and physical health care needs are met. This includes a member-focused
approach that helps make sure members get the right care, in the right setting, at the right time. Case
management services are available for all eligible members at the provider level.
In addition, HCIC’s Recover Wellness Program is a comprehensive integrated care model for TXIX
members with serious mental illness which builds on an Integrated Health Home (IHH) model for
achieving effective and efficient models of care for members. The model is based on best practices which
will achieve the CMS Triple Aim of better health for populations, better healthcare for the individual and
improved quality while reducing unnecessary costs.
Integrated Health Home Responsibilities
All members are assigned to an Integrated Health Home based on their home address, but may request
to receive services through another Integrated Health Home. Integrated Health Homes are responsible
for the full continuum of mental health and substance use disorders in inpatient, outpatient and
community based settings. The IHHs provide, refer, case manage and coordinate all required behavioral
health covered services.
For members with serious mental illness in the Recover Wellness population, the IHH is responsible for
also coordinating a comprehensive service plan that includes care for the member’s physical health
needs. Members receive:
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regular physical and behavioral health appointments
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health prevention screenings
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wellness programs that promote and support healthy lifestyles like smoking cessation, weight
reduction, exercise and stress management
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appropriate management of conditions, and
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health coaching/ health education to promote lifestyle goals and self-management
PCP Assignment
HCIC assigns a Recover Wellness member to a PCP within ten (10) days of the member being assigned
to the plan. HCIC attempts to preferentially assign members to the PCP associated with the Integrated
Health Home (IHH), but all HCIC members have the right to choose their own provider, and may call
Member Services for assistance in locating or selecting a PCP of their choice. The member’s PCP has
primary responsibility pertaining to the medical coordination of care duties, but will receive assistance
from the HCIC Integrated Care Managers. Special PCP assignments may be made to Pediatricians,
Internists, Nephrologists, Oncologists, etc. based on the medical needs of the member. The Member
Services Department and HCIC Medical Management will work collaboratively on these assignments to
ensure all clinical needs of the member are met.
HCIC instructs PCPs on their responsibility to communicate all known primary diagnoses, co‐morbidities
and changes in condition to the IHH. The IHH providers must provide pertinent diagnoses and changes
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in conditions, including medication changes, to PCPs in a timely manner as well. HCIC facilitates this
communication exchange as needed and maintains established monitoring activities such as record
review to ensure the exchange is occurring. HCIC initiates performance improvement in a timely
manner upon identification or awareness of deficiencies.
Timely Coordination and Exchange of Information
Health Choice Integrated Care facilitats the communication exchance of member record information as
needed and establishes monitoring activities such as record review to ensure that the exchange occurs
as follows:
 "Urgent" - Requests for intervention, information, or response within 24 hours
 "Routine" - Requests for intervention, information, or response within 10 days
Integrated Health Home Case Manager (Provider Level)
The Case Manager is employed by the IHH, and serves as the single point of contact for members. The
Case Manager supports the member’s needs by developing a personal relationship with the member,
collecting member information and helping the member navigate the system to obtain necessary
services and supports. The Case Manager works with the member/guardian/family and the ART/CFT to
develop the Individual Recovery Plan/Individual Service Plan (IRP/ISP) as per policy. The Case Manager
assists the member in maintaining, monitoring and modifying covered services and other necessary
resources. The Case Manager does outreach and engagement with the member when there is a missed
appointment or crisis contact. The Case Manager is responsible for communication and coordination of
care between the member’s ART/CFT and the member’s primary care provider. The Case Manager
works closely with the HCIC Integrated Care Manager when a member is identified as high need/high
cost.
CARE COORDINATION
HCIC ensures that coordination of care occurs at both the system level and at the provider level
depending on the member’s need, goals and functional status. Care coordination is provided by HCIC
care managers and provider clinical staff based on inter-agency collaboration with stakeholders, such as
other AHCCCS Contractors and primary care physicians, DDD, tribal nations, justice and law enforcement,
peer and family run organizations, DCS and other child-serving organizations.
Care coordination and collaboration ensure:
 Early identification of health risk factors and special care needs
 Coordination of covered services with community and social services that are generally available
through contracting or non-contracting providers, in the Geographic Service Area (GSA)
 Establish timely and confidential communication of clinical information among providers,
including coordination of member care between the PCP and other Health Choice Integrated
Care providers.
 Monitoring of the individual’s health status and implementation/revision of the IRP/ISP,
including periodic re-assessment and revisions to the IRP/ISP consistent with member needs
 Accurate and timely transmission of health care information, progress, services, lab reports,
medications and member needs
 Communication between providers, family members and stakeholders so that services are
delivered timely and meet the member’s needs, especially in resolving complex, difficult care
situations
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Educating and communicating with PCPs who treat any member with diagnosis of depression,
anxiety or Attention Deficit Hyperactiity Disorder (ADHD)
Participation in transitions to other RBHAs/ Health Plans, and in discharge planning from hospitals,
jails or other institutions to ensure timely services post-discharge, member engagement and
avoidance of gaps in care
Referral management for providers, services and community resources
Outreach and engagement of members who would benefit from services
For example, care coordination is provided in a and confidential manner that recognizes the importance of
Tribal Sovereignty and Nation Building, and meets the needs of tribal members through the development of
individualized tribal agreements.
HCIC works to coordinate member access to Medicaid and state funded services as permitted during the pretrial and post-release from jail or prison and during parole as per HCIC Memoranda of Understanding,
agreements and protocols for jails and prisons. This includes coordination of care with forensic peer support
programs and peer and family run organizations.
HCIC provides coordination of care for children with developmental disabilities through strong collaboration
with DDD and specifically via the HCIC Community Collaborative Care Team (CCCT). The purpose of the CCCT
is to facilitate communication, collaboration, coordination of services and fiscal management in order to
reach consensus and active decision making for the most complex DDD members.
DISEASE MANAGEMENT
Health Choice Disease/Chronic Care Management Program is designed to assist members diagnosed with
specific chronic and/or acute diseases maximize their health potential and increase the capacity to
manage their own medical care. Programs are developed based on selected disease conditions which
focus on members with high utilization of services, special at‐risk population groups and members at risk
or already experiencing poor health outcomes due to their disease burden and high volume/high
cost co‐morbid conditions.
The over‐arching goal is to maximize the health of R e c o v e r W e l l n e s s members with high risk health
and/or chronic conditions and to improve health outcomes while reducing associated co‐ morbid
conditions and control associated health care expenses. Disease management conditions are
selected based on the utilization of services, at risk population groups and high volume/high risk conditions.
HCIC also identifies members for participation in disease management programs through risk stratification
tools. HCIC has implemented multiple disease management programs focused on special healthcare needs,
high risk conditions, co‐morbid conditions, and chronic medical conditions.
In instances where a specialized disease management practice is involved, HCIC assigns a care manager with
expertise to support the providers’ delivery of services. Utilizing standard disease management practices, the
care manager will track and promote population-level evidence-based interventions and services that are
shown to improve outcomes.
HCIC also promotes self-management and prevention strategies such as health education, medication
adherence, family planning services and the Stanford Chronic Disease Self-Management program led by trained peer and provider Lay Leaders. HCIC currently uses three different Stanford Self-Management
programs—chronic conditions, diabetes and chronic pain. The goal of this program is to improve outcomes
as compared to Stanford data. Members complete pre and post questionnaires that include 10
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demographics questions, eight questions on health symptoms using Likert scales, six questions on
physical activities frequency, six questions on self-care confidence, four questions on home care
activities, and six questions on health care utilization. Answers are normed against Stanford data on
persons with chronic conditions who have taken the CDSMP. HCIC requires each provider to offer the
courses once per quarter with at least one course after hours or on a weekend.
Provider participation is a key element to any successful disease management program. Health choice
Integrated Care is there to support both the member and provider by:
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Fostering consistent and timely interventions based on the specific condition’s best practices
Educating providers on specific clinical guidelines/standards related to the member’s condition and
the desired outcomes that should be targeted in the treatment plan
Providing avenues for providers to be involved in the implementation of the program and the
member’s Care Management Plan
Monitoring outcomes at the member and provider level
In behavioral health, the leading causes of morbidity and mortality are suicide attempts, suicides,
unintentional overdoses, and substance abuse and misuse. HCIC has developed protocols and programs to
help members develop self-management skills and providers adhere to evidence-based guidelines.
Disease Management Programs include:
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Asthma – The goal of the Asthma Program is to improve the quality of life for qualifying members.
Diabetes – The Diabetes Program is designed to improve HbA1c testing and levels among diabetic
members. Members will also increase disease awareness and self-management of their medical
condition(s).
Hepatitis C – This program was developed to improve medication adherence for members diagnosed
with Hepatitis C and to improve overall compliance with the member's care plan.
Complex Care Management – The Complex Care Management Program is designed to provide high
quality case management to members with multiple and/or complex, and/or catastrophic injuries,
the frail and elderly, members in Special Needs Plans (SNP) and other members with high risk health
conditions.
High Risk Suicide Attempts-- The SHOUT (Safety, Help, Outreach/Organize, Understand, Track)
Program follows members for up to one year after high risk suicide attempts to decrease the risk of
repeat attempts or completion.
High Risk OB-- The High Risk OB program ensures that women have positive pregnancy and infant
outcomes.
Disease Management/ Chronic Care Program Evaluation
HCIC evaluates and monitors the effectiveness of each disease management program. HCIC monitors
the type and utilization of services to ensure appropriate care and services are delivered within specified
time frames. The decision to continue, modify or eliminate a program will be based on health
outcomes, member compliance and satisfaction, costs and utilization of health services. Measures are
dependent on the protocol. HCIC further ensure that any identified deficiencies are promptly addressed,
and Implements actions designed to bring the providers into compliance with the practice guidelines.
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Members with Special Health Care Needs
Members with special health care needs or members with special circumstances are likely to require
intensive care management or care coordination. Members with special health care needs are those
members who have serious acute and/or chronic physical, social, cultural, developmental or behavioral
conditions requiring medically necessary health and related services of a type or scope beyond that which
would generally be required by a member. Members will be considered as having a special health care
need when they have a medically related condition that simultaneously meets the following criteria:
 Condition will last or is expected to last one (1) year or longer
 An event(s) of a more acute nature, likely to transpire within a shorter time frame, but may result
in a significant negative health outcome
 Requires ongoing or adjunctive health or other resource intensive care not generally provided by
a primary care provider and/or the medical home
Health Choice Integrated Care assesses the R e c o v e r W e l l n e s s population to identify individuals with a
special health care need (each member and their condition is evaluated based on individual need and
enrollment population), as per AHCCCS Policy Manual Policy 540:
• Members diagnosed with HIV/AIDS
• Members also enrolled in the DD-ALTCS program
• Members with significant communication barriers, such as Limited English Proficiency (LEP), low
literacy, and visual or hearing impairments
• Members who are geographically isolated and/or are homeless
• Members transitioning out of jail or prison with serious mental illness or medical conditions
• Members transitioning out of the Arizona State Hospital
• Members who require health and related services of a type beyond that required by people in
general:
• Common and/or often mild chronic health issues with unique presentations, such as multiple allergies
or asthma
• Complex, but manageable health conditions, such as congestive heart failure, COPD, high risk
pregnancy, chronic pain
• Complex and difficult to address health issues such as lupus, cerebral palsy, major functional
disabilities
• Targeted disease conditions, such as Hepatitis C and Hemophilia, insulin-dependent diabetes
• Physically disabled adults and frail elderly
• Organ transplant recipients or transplant candidates
• Members who have dual eligibility coverage and/or who are unfamiliar with navigating the health
care system.
Once a member is identified as a candidate for care management or care coordination, HCIC assigns an
HCIC care manager who will be best suited to understand the member’s medical needs. The care
manager will complete an initial assessment of the member’s health conditions, social environment,
current functionality and overall needs. The care manager will coordinate services with the Integrated
Health Home to ensure the member understands who their PCP is and assist with PCP reassignment
when indicated. If the member has not yet established care with their assigned PCP the care manager
will ensure the member’s case manager assists the member with a new patient appointment. All clinical
member information sharing is in accordance with state and federal privacy requirements.
Direct Access: Members identified with special health care needs are allowed direct access to specialists
when appropriate for their medical condition and current situation.
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14.1 – CARE MANAGEMENT
HCIC’s care management program design promotes and supports “seamless” care coordination across the
entire delivery system by offering members a single point contact for whole health treatment, while also
offering a central point of clinical responsibility for outcomes from a managed care perspective. Data and
support will be shared between the providers and HCIC in order to eliminate blind spots and gaps in medically
necessary care. This is achieved through a step by step approach that begins with an initial assessment to
determine the member's specific care coordination or care management needs and the development of a
Care Management Plan for members in the Top Tier, which is estimated to be about 20% of the members.
Care Management is an administrative function that is not the day-to-day duties of case management or
service delivery.
RESPONSIBILITIES
Health Choice Integrated Care has established a policy for a Care Management program that in
order to:
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Identify the top tier of high risk/high cost members with Serious Mental Illness (SMI) in a fully
integrated health care program (estimated at twenty percent (20%)
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Effectively transition members from one level of care to another
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Streamline, monitor and adjust members’ care plans based on progress and outcomes
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Reduce hospital admissions and unnecessary emergency department and crisis service use
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Provide members with the proper tools to self-manage care in order to safely live, work, and
integrate into the community to include:
o Providing all insulin dependent diabetic members discharging from the AzSH with the same
brand and model glucose monitoring device as used in the hospital
o Informing members of particular health care conditions that require follow up
o Informing members of their responsibility to follow prescribed treatment regimens
GENERAL REQUIREMENTS
For all members determined to have a SMI diagnosis who are receiving physical health care services
through the Integrated RBHA, Health Choice Integrated Care must:
• Establish and maintain a Care Management Program (CMP).
• Allow the member to select (or Health Choice Integrated Care to assign) a PCP or BH clinician who is
formally designated as having primary responsibility for coordination of the member’s overall health
care
• Educate and communicate with PCPs who treat depression, anxiety and ADHD
• Identify members with special health care needs and:
o Ensure an assessment by a qualified health care professional for ongoing needs is completed.
o Ensure ongoing communication among providers.
o Ensure that a mechanism for direct access to specialists exists, as appropriate.
• On an ongoing basis, utilize tools and strategies to develop a case registry for all SMI members which
at a minimum, will include:
o Diagnostic classification methods that assign primary and secondary chronic co-morbid
conditions;
o Predictive models that rely on administrative data to identify those members at high risk for
over-utilization of behavioral health and physical health services, adverse events, and higher
costs;
o Incorporation of health risk assessments into predictive modeling in order to tier members into
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categories of need to design appropriate levels of clinical intervention, especially for those
members with the most potential for improved health-related outcomes and more cost-effective
treatment; and
o Criteria for identifying the top tier of high cost, high risk members for enrollment into the Care
Management Program.
Assign and monitor Care Management caseloads consistent with a member’s acuity and complexity
of need for Care Management.
Allocate Care Management resources to members consistent with acuity, and evidence-based
outcome expectations.
Provide technical assistance to Care Managers including case review, continuous education, training
and supervision.
Communicate Care Management activities with all of the Integrated RBHA’s organizational units with
emphasis on regular channels of communication with the Integrated RBHA’s Medical Management,
Quality Management and Provider Network departments.
Establish communication to exchange information within 7 days between PCP and Behavioral Health
provider, including monitoring to ensure coordination and remediation if the communication does
not occur.
Have Care Managers who, at a minimum, will be required to complete a comprehensive case analysis
review of each member enrolled in the Integrated RBHA’s Care Management Program on a quarterly
basis. The case analysis review shall include, at a minimum:
o A medical record chart review
o Consultation with the member’s treatment team
o Review of administrative data such as claims/encounters
o Demographic and customer service data
ELIGIBILITY
Health Choice Integrated Care’s care management program is available to all enrolled members in the
Recover Wellness Program. The assessed needs of the member determine the level and type of care
management. High need/high cost identification factors include members with actual or predicted risk for:
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Avoidable hospital admissions and readmissions
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Unnecessary emergency and crisis utilization
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Morbidity and mortality due to over or under-utilization of services (including pharmacy)
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Multiple active co-morbid chronic conditions
MEMBER IDENTIFICATION FOR CARE MANAGEMENT
Health Choice Integrated Care utilizes data from multiple sources to identity members who may benefit
from care management to meet their individualized needs. These tools allow for members to be
stratified into a case registry and their specific risks identified, including chronic co-morbid conditions
and specific gaps in care. Members may be identified through population-based tools (i.e., predictive
modeling) and individual-based tools (i.e., Health Risk Assessment [HRA]). HRAs are combined with
predictive modeling reports to further identify members that may need care management. These
reports also assist in identifying the appropriate care management level, particularly for those
members with the greatest potential for improved health outcomes and increased cost-effective
treatment. In addition, members are identified for care management through various referral
sources from within Health Choice Integrated Care and through external sources.
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These referral sources include, but are not limited to, the following:
• Member self-referral
• Family and/or caregiver
• Interdisciplinary Care Team
• Medical Management (UM) referral
• Quality Management (QM) referral
• Grievances
• Incident Accident Death reports
• Discharge planner referral
• Provider referral
• Provider submissions of the American College of Obstetricians and Gynecologists [ACOG]
comprehensive assessment tool
• Provider submission of an Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Tracking
Form
• Division of Behavioral Health Services (DBHS)
• AHCCCS
• Department of Economic Security (DES)/Division of Developmental Disabilities
To make a referral to the Care Management program, through HCIC Member Services: 1-800-640-2123.
CARE MANAGEMENT PLAN
The HCIC Integrated Care Manager will develop and implement a Care Management Plan for each TXIX
member who is SMI in the Top Tier. The Care Management Plan will be consistent with the IRP/ISP, but does
not take the place of it. The Care Management Plan incorporates the member’s physical and behavioral
health needs at a much higher level than the IRP/ISP, focusing on areas that have traditionally been
overlooked or are high need.
The Care Management Plan describes the clinical interventions and services recommended to the ART/CFT,
based on an administrative review of the member’s health risk assessment, identified needs, consultation
with the member’s treatment team, claims, IRP/ISP, diagnoses, predictive modeling and best practices done
on a quarterly basis.
The content of the member’s Care Management Plan will be documented and maintained using EXL Landa’s
CareRadiusTM suite of care management software products which will be available to the 24 hour Crisis
System and Nurse Advice Line, and will be shared with the IHH team.
The Care Management Plan includes:
 Clinical interventions recommended to the treatment team
 Strategies for successful transitions between levels of care/facilities/providers, discharge planning
and coordination of care gaps
 Delineation of responsibilities for involved providers across systems for monitoring referrals and
follow-up specialty care
 A schedule for routine health care services, medication monitoring, prevention, EPSDT, disease
management and health promotion activities
 Strategies, such as health coaching and wellness, to facilitate behavior change to address underlying
health needs and member self-management.
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CARE MANAGEMENT TRANSITION AND FOLLOW-UP
Members will be transitioned from the Top Tier Care Management program to less intensive care
coordination when their Care Management Plan goals have been achieved, when they no longer have active,
uncontrolled behavioral or chronic disease symptoms, or when they show demonstrated improvement in
overall health and self-management outcomes. HCIC will assess the member’s condition prior to transition
from Top Tier Care Management. Members will still receive ongoing medically-necessary services, care
coordination and case management services through their assigned IHH. Care coordination services will be
available to all individuals with SMI through the Integrated Care Managers even if not identified as high
need/high cost.
HEALTH OUTCOMES MONITORING
HCIC actively monitors outcome measures to demonstrate the value of providing whole-person health care in
an integrated setting. HCIC conducts a quarterly and annual evaluation of the Top Tier Care Management
program, to identify areas of improvement and program enhancements.
Key metrics to assess integration will include all measures identified in the Scope of Work and as directed by
ADHS/DBHS, member experience and cost-effectiveness, as well as measures that assess integration of
clinical and administrative service delivery, such as ED utilization, inpatient admissions, re-admissions, crisis
services, adverse events, average lengths of stay and costs. Further, outcome summaries including
evaluation of the effectiveness of care coordination are reported to the Health Choice Integrated Care
Madical Management Committee and to ADHS/DBHS as required.
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