Hawaii Medicaid streamlines its referral process for children

Providing case management and care coordination for children is not merely an option for providers in Hawaii's Medicaid program; it is a requirement in their contracts. The agency recently began monitoring how many children are actually receiving these services.

"We're able to see whether care coordination is only occurring in some areas and not others," says Patti Bazin, Health Care Services Branch Administrator of the Med-QUEST program, which covers non-disabled children. "We don't just want to assume that children who need this are getting it. We want to be able to validate that. This is a way for us to close the loop with doing that."

In addition, each child enrolled in QUEST Expanded Access (QExA), the state's newest program for the aged and disabled, has a service coordinator. Within 15 business days of a child's enrollment, the health plan is required to do a health and functional assessment on the child, in order to be certain he or she is receiving the needed services.

"If you can avoid an unnecessary hospitalization, there is a cost savings, but the quality of care for the child is also going to be better," says Leolinda Parlin, a consultant for the program and state coordinator for Family Voices of Hawaii. "It wasn't that we identified any specific problems. But one of the things we are really trying to do is be sure that our health plans, which provide our Medicaid services, are doing the work they are supposed to be doing."

To address this, a supplementary form was developed that tracks the services being provided during each visit. "What makes this revolutionary is that where some states use forms for every screening, we have gone to one form," says Ms. Bazin.

At the time of the child's visit, the physician is required to make a decision about whether care coordination is needed. It may be that a box is checked stating that the family needs to be contacted about language access issues, which could be handled internally within the Medicaid program, or that early intervention is needed, which requires an external care coordinator.

"The form triggers that and mobilizes it," says Ms. Bazin. "So we strengthened, at the point of the visit, that initial care coordination." When the form was first implemented, however, it was discovered that many physicians weren't aware of available community resources.

"So, this strengthened the relationship with the health plan's EPSDT [Early Periodic Screening, Diagnosis and Treatment]. The doctors often did not realize to what extent the health plans were there to assist them," says Ms. Bazin. "They became aware that there were other people in the program that were responsible."

A structured referral system was also created. "That means that care coordination will very likely be interfacing with children's services and the school system. They are the ones who are really at the nexus of trying to figure out what pieces have to be put in place for continuity of care," says Ms. Bazin.

With the new approach, children are referred for services more expeditiously. In one case, a 6-year-old was receiving services through her community physician, a pediatrician, and there was a concern about self-injurious behavior. "He didn't know who to refer the child to and was stuck in trying to get a behavioral health referral," says Ms. Parlin. "The coordinator had more leverage, because there is more [than] one person involved. You are bringing in the resources of the whole organization."

While the pediatrician was initially trying to work through an individual psychologist, the coordinator was able to tap into the network of the entire health plan to negotiate services for the child. She spent two days tracking down a psychologist, who quickly implemented a treatment plan including individual and family therapy.

"The child received services much sooner because of the coordinator's involvement. And, in looking at the family as a whole, the coordinator also got the mother enrolled in Medicaid," says Ms. Parlin. "In this regard, I think Medicaid really came through for this child and this family. That is the outcome we all hope and dream of."

Contact Ms. Bazin and Ms. Parlin at (808) 791-3467.