Care coordination helps seniors stay independent
Team develops a person-centered plan
Since Medica care coordinators began working with dual eligible seniors to help them live safely at home, the proportion of Medica members in the program who live on their own in the community has increased from 39.4% to 71%.
Medica’s program for dual eligible seniors offered through the Minnesota Senior Health Options programs combines medical care coordination and psycho-social support to help seniors live independently in the community.
- Care coordinators visit seniors at home and complete a comprehensive health risk assessment.
- They help seniors access services ranging from snow shoveling to home-delivered meals to adult day care.
- Care coordinators assess seniors in person at least once a year or whenever there is a change in health status.
The program, offered through the Minnesota Senior Health Options program, combines health programs and social support systems into one program.
Members who enroll in Minnesota Senior Health Options are assigned a care coordinator who is either an RN or licensed social worker. The care coordinator contacts the member and sets up a time to go to the member’s home and completes a 25-page comprehensive health risk assessment. The assessment looks at the person’s living situation and activities of daily living, and includes a complete healthcare screening.
"We develop a person-centered plan of care and take into consideration what the member wants to do, what they no longer can do because of changes in their health, and what services we need to put in place to help the person live in their home environment as long as possible," says Julie Faulhaber, MBA, vice president and general manager of state public programs for the Minnetonka, MN-based health insurer.
The program serves a wide range of members, says Kristy Wilfahrt, RN, director of dual eligible and care system products for Medica. "Some are pretty healthy seniors and others need more help. Sometimes the family is able to assist them and sometimes they are not. Some are so frail and have so many needs that they require a nursing home for a permanent residence," she adds.
After the plan of care is developed, the care coordinators follow up with the members’ primary care providers and provide a summary of the assessment along with a copy of the plan.
The care coordinator conducts a home visit at least annually or more often if the member has a change in condition.
The care coordinators may go to physician appointments with seniors to assist the senior, explain the care plan and medications, and answer questions. They also help seniors access services to help them remain as independent as possible, such as home care, adult day care, transportation assistance, home-delivered meals, and line up people to mow the lawn or shovel snow. They may arrange for a podiatrist or a therapist to visit them in their homes. They work with the Medica customer service team to arrange transportation for activities that are beyond the normal medical benefits, such as rides to church or adult day care services.
"We look at the community for assistance to our members. For instance, there may be a neighbor or a member of the parish who can drive members to church," Wilfahrt says.
The care coordinators live in the communities they serve and are familiar with services in their community that the seniors can access, she says. For instance, the care coordinator may know the pastor of the church the member attends and can find out if there are members who can assist the senior. They connect with local civic organizations, such as the Lions Club and American Legion, which may offer assistance in obtaining equipment for people who need them. The care coordinators follow up regularly by telephone and at least once a quarter in person. Any time the members go to the hospital or emergency department, are discharged from a skilled nursing facility, or have a change in health status, the care coordinators reassess them to determine if the plan of care should be modified. "We are notified about 90% of the time a member in the program accesses the healthcare system," Faulhaber says.
Often, the care coordinators can help members with transitions of care as they move from one facility to another. "Navigating the healthcare system can be difficult, especially when people are stressed. The care coordinator can be a resource for patients and family members whenever they need assistance," Faulhaber says.
Care coordinators are supported by a highly licensed clinical social worker and a registered nurse, called clinical liaisons, who can help identify resources and other solutions if a member has unique needs. "They are another pair of eyes and ears in support of the care coordinators. They not only support our members, they support the care coordinators as well," she says.
The program provides services to seniors in both urban and rural areas throughout Minnesota. The care coordinators may be employed by Medica or community agencies or care systems with which the insurer contracts.
Medica arranges continuing education sessions twice a year which care coordinators may attend in person or by conference call. In addition, the clinical liaisons and operations manager visit each care coordinator entity at least twice a year and provide updates to the program in person.
"There is a huge value in having face-to-face conversations with the care coordinator. We can answer questions and find out what is working and what is not," she says. The care coordinators have access to a website that includes policies and procedures, forms and other tools, helpful hints for working with the elderly, and a database of resources.
