MHS Care Management Program 1017.PR.P.PP.1 10/17
Sample Integrated Transitional Care Model
Inpatient Admission Process Admission thru discharge and beyond Goals: Ensure safe and timely transitions of care (TOC) Reduce all cause readmissions
MHS Points of Transition Concurrent Review Nurse (CCR) • Reviewing the case for identification and anticipation of member/patient needs Discharge Planner (DPT) • Further anticipates discharge needs and facilitates the transition to the next level of care Post DC Outreach Nurse • Ensures that the transition occurred safely and successfully and identifies continued needs requiring care management Case Manager (CM) • Continues to ensure that the transition of care occurred safely and educates the member/patient to their complex medical needs as well as key topics that can help prevent readmission to the hospital Care Coordinator (CC) • Provides care management services for non-clinical service needs Disease Manager (DM) • Provides education to members/patients with stable chronic conditions
Potential Outcomes of a Poor Transition of Care Medication errors Stress for the patient and caregiver Continuation or recurrence of symptoms Visits to the ED Readmission to the hospital
Poor transitions can lead to hospital readmissions
Readmissions Health care reform has pinpointed hospital readmissions as a key area for improving care coordination Drivers of readmission rarely result from a singular breakdown Average of nine (9) factors that contribute to each readmission (Kaiser Permanente) Evidence shows that supporting patients through care transitions can reduce re-hospitalizations
Types of Readmissions and Who Could Have Impacted Readmissions because of poorly managed transitions during discharge CCR and DC Planning team Readmissions because of a recurrence of a chronic condition that led to the initial hospitalization Care Management team
MHS Discharge Planning Team Coordinate care for the member/patient from inpatient to home or the next level of care to ensure a smooth transition Alleviate discharge barriers Discharge planning begins on the day of admission
Role of the Discharge Planner Evaluate the plan Modify the plan as applicable Ensure that services are in place Assist with removing barriers to discharge Communicate the discharge plan to appropriate team members, both internal and external
Levels of Care Management Disease Management – provide education, knowledge and tools necessary to effectively manage previously identified chronic conditions (Asthma, COPD, Diabetes, CAD, CHF, etc) Care Coordination – telephonically assist members/patients with primarily psychosocial issues such as housing, financial, etc. with need for referrals to community resources or assistance with accessing health care services Case Management – telephonically assisting members/patients requiring a higher level of service, with clinical needs. These members/patients may have a complex condition or multiple co- morbidities that are generally well managed Complex Case Management – Assisting members/patients either telephonically or face to face with complex, high-cost, high-risk, or co-morbid conditions, including members/patients classified as children or adults with special needs
Levels of Care Management Complex Case Management (adult, CWSN, BH, High risk OB) Case Management / Disease Management Care Coordination / Care Navigation
Goals of MHS Care Management Assist our members in achieving optimum health, functional capability, and quality of life through improved management of their disease or condition Assist our members in determining and accessing available benefits and resources Collaborate with our members, family, providers, and community organizations to develop goals and assist members in achieving those goals Assist our members by facilitating timely receipt of appropriate services in the most appropriate setting Maximize benefits and resources through oversight and cost- effective utilization management
MHS Case Management Functions Early identification of members who have special needs Assessment of member’s risk factors Development of an Integrated “Member Self-Management” plan of care in concert with the member and/or member’s family, primary care provider, and managing providers Development of an Integrated Provider Care Plan in concert with the provider when members refuse or is unable to participate but has been identified as potentially high risk and in need of case management Identification of barriers to meeting goals included in the plan of care and develops interventions to overcome those goals Referrals and assistance to ensure timely access to providers
MHS’ Pillars of Case Management Medication Self- Timely Follow Up to Disease Specific Management Care Education • Medication • Follow Up • General education to Recommendations appointments disease state scheduled? • What to take, when to • Discussion around take, how to take • Preventive Care co-morbidities medications Visits scheduled? • Red flags and what to • Who to call if side • Barriers to scheduling do, who to call and effects develop or making when to call if they appointments arise • Barriers to obtaining medications • Transportation • Evaluation of Gaps in services needed? Care
Types of Interventions Related to Medication Self-Management Medication reconciliation with d/c instructions and appropriate providers as needed. Medication education including: • what to take • when to take it • how to take the medication • side effects of the medication • Who to call if side effects develop Education to the importance of medication adherence
Types of Interventions Related to Timely Follow Up to Care Determine if the patient is part of a medical home and if not, assist in facilitating this Determine how long it has been since their most recent well visit Provide the providers’ phone number to the patient/care giver Ensure follow up appointments are made Ensure transportation arrangements to and from the appointment are in place Assist the patient in developing a list of questions for their appointments Field case managers offer to attend appointments with the patient if they would like them to do so
Types of Interventions Related to Disease Specific Education Thorough review of discharge instructions and/or provider instructions with the member / caregiver Education around the patient’s specific diagnoses including: co-morbidities, care opportunities associated with the condition and warning signs or red flags that their condition is worsening Education around who to call if warning signs arise
Consideration for Case Closure from Case Management Does the patient understand self management? Does the patient understand their benefits covered by the plan (transportation, care coordination, etc.)? Does the patient understand their disease and warning signs that their condition may be worsening? Does the patient know who to call if their condition is worsening? Does the patient understand their medications and the importance of adherence? Have all of the identified problems been resolved? Is it appropriate to make a referral to another discipline? Is the patient successfully self managing?
How to Reach Us Customer Service Phone 1-877-647-4848 1-800-743-3333 TTY/TDD Option 1: Hoosier Healthwise Option 2: Healthy Indiana Plan (HIP) Option 3: Hoosier Care Connect Hours of Operation Monday – Friday 8 a.m. – 8 p.m. Customer Services: Member Handbook, Transportation, Find a Provider, Complaints 24/7 Nurse Advice Line 1-877-647-7878 Access to Transportation Services 1-877-647-4848 (Schedule 72 hours prior to appointment) 1-800-743-7333 TTY/TDD Heather Bradley 1-877-647-4848, ext. 20928 Senior Director, Complex Case Management Deb Detro 1-877-647-4848, ext. 48836 Senior Director, Case Management
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