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When individuals who are eligible for both Medicare and Medicaid are enrolled in WellCare Health Plans’ special needs programs for dual eligible beneficiaries, a case manager meets with them in their home or other care setting and conducts a thorough assessment of the individual’s needs, says Pamme Taylor, vice president for advocacy and community-based programs for the Tampa, FL-based managed care organization.
"Meeting these individuals in person is essential in establishing rapport and building a relationship. The individuals need to trust us before they reveal the details of their life circumstances, which are so critical to know in developing a plan of care," she says.
WellCare’s special needs plans for dual eligibles differ slightly depending on the Medicaid rules in the state in which they are administered, but in all instances, the case managers work closely with the members and all of their healthcare providers to make sure all of the members’ medical, behavioral health, and social needs are met, she says.
The case managers WellCare assigns to work with the dual eligible population must be detail-oriented and able to ask probing questions, but at the same time, they should understand human nature and be caring and sympathetic, she says. "The people who are dually enrolled have so many health issues and so many barriers to care. We have to spend a lot of time identifying all the nuances," Taylor says.
Over time, the clients get to know the case managers and bond with them, often revealing information and problems they never would tell their healthcare provider. "We don’t act like representatives of an insurance plan. That doesn’t build a level of trust. We treat them as if they are our family and that their health and well-being is important to us," she says.
WellCare’s health risk assessment involves far more than just asking a set of questions, Taylor says. The case managers, usually nurses and social workers, look at the individual’s living environment, social support system, and physical condition and get all the information needed to develop a plan that makes the most sense for them.
"We look at everything — the circumstances at home, the person’s support network, the physical, mental, and social services that they need. We make sure they live in a safe environment and can dress, groom, and feed themselves. We determine if they have a social support system, if they have access to transportation, if they need help with home maintenance or lawn care, and on and on," she says.
The case managers also assess the needs of the caregivers. "We may not be able to provide actual care for the caregiver, but we do give support to help them assist the patients with their activities of daily living," she says.
The care manager takes the information gathered during the assessment and works with WellCare’s interdisciplinary team to develop and implement a care strategy. The team includes social workers, nurses, a medical director, and a behavioral health coordinator. The team involves family members and/or the primary caregiver for the individual and drills down to determine what is happening in the patient’s life and what kind of support is available in the home.
"Our interdisciplinary care team cannot provide treatment for the patients. That is provided by their physician office and other members of our network. Our team devises a care plan based on what we see in the home but they also work closely with the clinicians to make sure the individuals get everything they need," she says.
The WellCare team regularly holds grand rounds on each patient to make sure all the bases are covered.
"We have a view of the entire care continuum, something the individual providers don’t have. The behavioral health clinics have a piece. The primary care providers have a piece. We bring it all together," she says.
The case managers visit patients in their homes at intervals determined by patient needs and follow up by telephone between visits.
When the nurses visit the homes or follow up with patients on the telephone, they often uncover new symptoms or life circumstances and alert the primary care provider or behavioral health professional. For instance, Taylor says, one patient with a comorbid diagnosis of depression was hospitalized for a medical condition. When the case manager called to confirm that the patient had transportation to her follow-up appointment, she learned that the family’s dog had died. She alerted the patient’s physician, who arranged counseling and ensured that the medication regimen was stable to help the patient during the grieving process.
The case manager who performs the assessment has the primary relationship with the individual in most cases but sometimes may not have the clinical expertise to be the lead on the case, Taylor says. For instance, if a patient is severely depressed as well as having a medical condition, a behavioral health clinician may take the lead until the depression is resolved while the nurse coordinates the clinical part of the treatment plan.
The case managers have access to a social safety net database with detailed information on all the available social service organizations and other resources in the community. The database is organized by ZIP code so the case managers can locate organizations that are convenient to the members.
WellCare hired teams of researchers to create the database and piloted the process in Kentucky, starting with 2,500 organizations. Now, three years later, the database includes 6,700 organizations that represent about 300,000 services.
"We also created an electronic health record just for social services. Every time we connect a member to the social program, we track who the member is, what services they need, what organization they are referred to, and whether the person actually received the services. We are working to automate the process so the case manager can send referrals directly to the organizations," Taylor says.