Face-to-face visits enhance senior population care

CMs see condition of home firsthand

When members are enrolled in Minnesota Senior Health Options from UCare Minnesota, their case manager visits them in their home to meet them and complete an extensive assessment to determine their needs and a plan of care.

"With face-to-face visits, we can get a better understanding of the member's home environment and check for fall risks and other problems. A personal visit allows us to see firsthand what the conditions are in the homes and determine what services are needed to ensure that people have what they need to keep living in their homes. It's much easier to develop a trusting relationship when we meet with a member in person, rather than over the telephone," says Cindy Radke, LSW, a case manager for UCare Minnesota, which administers the Minnesota Senior Health Options plan for the Minnesota Department of Human Services.

Members eligible for the program must be 65 or older and be eligible for Medical Assistance, with or without Medicare parts A and B.

The goal of the program is to provide assistance to the senior population that will keep them out of the hospital and allow them to live in their homes, rather than a nursing home or assisted living center.

The case managers work with patients to develop a care plan that allows them to maximize their health care benefits. They assist the member by helping with paperwork, making appointments, and following up to see that the services were provided satisfactorily.

They can refer members to disease management programs and other programs to help them stay out of the hospital.

The case managers can schedule nurse visits for medical care or to educate the members on their medications, delivery of food, home health aides who help with activities of daily living, transportation to and from medical appointments, and caregiver training.

"We also help with socialization. We can arrange adult day care, adult foster care, respite care, or senior companion services. We assist the seniors in arranging physician, dental, and vision appointments among others," Radke says.

The case managers conduct a face-to-face assessment in the member's home at least every six months and follow up by telephone at regular intervals, depending on the member's needs. "We may see the senior once a month or even more frequently if they have a lot of medical needs," she says.

Case managers in the UCare Minnesota Senior Health Options program manage the care of 70-80 members at a time. They take laptops into the members' homes to complete the assessment and use the health plan's case management software to set up reminders for when it's time to contact the members again.

The case managers are assigned by clinic and work with the clinic staff to manage the care of members who are patients at the clinic. "This arrangement allows us to develop a close working relationship with the clinic physicians and nurses, and this helps us collaborate to provide better care for the members," Radke says.

Because the health plan's membership includes people from other countries who have immigrated to Minnesota, the case managers tend to carry a diverse ethnic caseload.

Radke has a caseload with a significant number of members from the Hmong community. When she manages their care, she works closely with Maiyer Vang, BS, associate case manager, who is Hmong and speaks the language.

If the member is Hmong, Vang accompanies Radke on the home visit and follows up with the member later to make sure that the services he or she needs are in place.

Radke makes the home visits alone to English-speaking members.

Members are more comfortable and relaxed when a person from the same background who speaks their language is there with the case manager to help complete the assessment, Vang adds.

"There is a level of trust, especially when they know you are the same race and that you will be there to help them navigate the health care system as efficiently as possible," she says.

The face-to-face visits are especially effective with a population that is not familiar with Western medicine, Vang says. "I am able to establish a much better relationship than if I were a disembodied voice on the telephone. Understanding the Western health care system is challenging for everyone, but it's even more difficult if you can't speak the language and have different cultural beliefs and values, traditional practices, and personal beliefs."

Language problems become more acute when the conversations are conducted over the telephone, which is what makes the face-to-face meetings particularly effective, Radke points out.

"With individuals of a different background who don't speak the language, anything other than face-to-face is not as satisfactory," she says.

Having a person who understands the Hmong language and culture makes it easier to find appropriate services because Vang knows what resources are available in the Hmong community. Since she is familiar with the cultural beliefs of the Hmong population, she makes sure they are taken into account when the plan of care is created, Radke says.

For instance, the majority of the Hmong elderly population relies heavily on adult children to make their health care decisions. That makes it extremely important to make sure that the adult children in the family are involved developing the plan of care, Vang explains.

"Often people from the Hmong community don't speak English, and they may not understand Western medicine. We look at their traditional beliefs and how they compare with western medicine and work to meet the health care needs of the seniors without interfering with their cultural practices," she says.

Whenever possible, the health plan uses someone other than family members as an interpreter for the members from other ethnic backgrounds.

"It helps that UCare employs people from a diverse ethnic background. Staff who speak the language can better communicate with members than if we use an interpreter," Radke says. If there is no internal interpreter, the health plan arranges for an outside interpreter.

In addition to staff members from the Hmong community, UCare Minnesota employs other staff members who are Somali and Spanish, two other large populations the health plan serves.

The company provides cultural competency training as part of the continuing education seminars for its staff.