CMs coordinate care for special needs population
Members have comorbidities, multiple disabilities
It’s not unusual for a care manager in Horizon NJ, Health’s Care Coordination Unit (CCU) to get a thank-you note or a telephone call from a member or their relative enrolled in the managed care organization’s program for publicly insured members with special needs.
"Many of the members are initially afraid of being enrolled in a managed care program, but once they have someone to help them negotiate the health care system and someone to advocate for them, they really appreciate the services," says Pamela Persichilli, RNC, director of clinical operations for the Trenton, NJ-based managed care organization.
Horizon NJ Health began the CCU for its special needs population in 2000 to better serve members with chronically disabling conditions, ranging from quadriplegia and paraplegia to Down syndrome and autism.
"We are highly involved with our state agency, who is our partner. They have shared some great suggestions that helped us develop the program as they became aware of the evolving needs at the state level," Persichilli says.
Members range in age from young children to the elderly, and many have multiple comorbid conditions, including mental health problems.
"This is a population that needs a lot of advocacy and care coordination," Persichilli says.
A multidisciplinary team working with the special needs population includes the medical director, social worker, case manager, and mental health specialists if needed.
The case managers work with the primary care physician, specialists, and any community agencies that may be involved in the member’s care. For instance, if the person is younger than 20, the school system is part of the care plan.
Members with special needs are identified through external or internal referrals and enrollment in state-sponsored programs.
Outreach workers, specially trained to relate to and coordinate services for the special needs population, make the initial calls to members who are referred to the program.
The outreach workers, many of whom are bilingual, sit side by side with the case managers and immediately transfer a call to a case manager if the member needs a complex needs assessment.
"Our nurses concentrate on coordinating care for our members as opposed to doing administrative jobs, like tracking down the members. But they are right there in case the outreach worker finds someone who needs immediate assistance. It is seamless to the member," Persichilli says.
If the outreach worker can’t reach the member by telephone, the health plan sends him or her a letter. The case outreach worker may work with the primary care physician, a dentist, or the school system’s special needs program to get in touch with the member who is eligible for services.
"We are very aggressive in our outreach," Persichilli says.
When a new member is referred, the case managers immediately begin the transition plan from the member’s fee-for-service to Horizon NJ Health’s managed care coverage.
"We build a transitional plan to make sure the transition from fee-for-service to a managed care model is seamless," Persichilli says.
Even if a nonparticipating provider is treating the member, Horizon Mercy will approve that provider until the member is transitioned to someone else or the provider contracts with the managed care plan.
"We want to maintain the continuity of care so we continue to work with the original provider until we can transition the member to a contracted provider," she says.
The care managers conduct a complex needs assessment, then get in touch with all the disciplines that have been treating the member. They send the care plan to the primary care physician, identify any other needs, such as a high-risk dentist, and coordinate with the case manager or special needs coordinator in the school district.
They get in touch with the county’s Medicaid case manager who is coordinating the Medicaid services and assesses what community linkages are needed.
They identify home health care and home laboratory needs and other services the member may need. For instance, if the member is a quadriplegic or paraplegic and can’t get to appointments, the case manager identifies a primary care physician who makes home visits and arranges for the care.
The case manager talks with the member and family, identifies their goals, and works with them to meet those goals. For instance, one care manager works with a member with multiple muscular problems whose goal was to increase her mobility.
The care manager found a specialist in another part of the state who could help the member increase her mobility. After coordinating the care, the case manager drove four hours on a Saturday to visit the member and her mother at the hospital.
"It made a tremendous difference to the member and in her feelings about herself. She had been feeling very inadequate because she couldn’t help herself," Persichilli recalls.
Case managers in the CCU typically carry a caseload of 40-50 members. The plan uses an assessment tool to stratify the members with Level 3 as a designation of the sickest of the sick. The goal is for each case manager to handle five or fewer members who are on Level 3.
Level 3 members receive phone calls as frequently as every day and no less than once a week. Usually about half of a case manager’s clients are on Level 2. After the plan of care and services are in place, the case managers generally check on these members every month. Level 1 members get phone calls every few months but are encouraged to call any time they need anything or have questions.
The nurses who are care managers are highly specialized in the various modalities that the members in the program are likely to need. Among them are an oncology nurse, an infectious disease nurse, a nurse specializing in pediatric disabilities, another with a background in adult disabilities, and nurses with a certified background in home health.
"Our nurses are experts in very specific, specialized areas. We bring them together as a group and get a great cross-reference of all the specialties. However, all of the care managers are skilled in coordinating the care of the special needs population and can take over whenever a colleague is not available," Persichilli says.
The teams hold weekly adult case conferences and weekly pediatric case conferences to discuss all Level 3 members at high risk.
The social worker case managers are part of the team that creates the care plan and facilitates linkages to community agencies. They are located next door to the CCU care managers and work closely for them.