Coordination of Care for Persons with Disabilities Enrolled in Medicaid Managed Care: A Conceptual Framework to Guide the Development of Measures. VI. WHAT PROCESSES/ACTIVITIES ARE INCLUDED IN CARE COORDINATION?


What processes and activities are needed to achieve these intermediate and long- term outcomes? Based on the literature and our discussions with experts, we have identified the following list:

  1. Outreach and identification of individuals in need of care coordination (Leutz, personal communication).

  2. Assessment of the current health, functional and psycho-social status of the patient and family (Bulger, personal communication).

  3. Assessment of the home and community context of the patient and family (Mack, personal communication).

  4. Identification, with patient and family, of their health and functioning goals and their preferences with respect to receipt of services (Brede, personal communication).

  5. Identification, with patient and family, of the resources and assets they bring to achieving goals (Mack, personal communication).

  6. Education of the patient and family of the resources and services which are, and are not available within the MCO and in the community (Leutz, personal communication).

    • This would include providing information regarding the rules and procedures of the MCO with respect to accessing services, appealing denials of service, and making complaints grievances.
  7. Specification (in collaboration with the patient and/or family) of service needs (current and likely short and mid-term future), including medical care services, enabling and support services provided by the MCO and related social and educational services that could be provided by other agencies and individuals (Leutz, personal communication; Ziring, personal communication).

  8. Articulation of a plan for accessing these services, within and outside the MCO (Bulger, personal communication).

    • Note that some elements of the plan may be carried out by the patient and/or family.
  9. Developing the plan in writing and delivering it to the patient and/or family (Moore, personal communication).

  10. Arranging for the receipt of these services, in a manner as close as possible to the preferences of the patient and/or family.

  11. Facilitating ongoing communication between care coordination staff, clinical providers and administrative staff of the MCO regarding patient status, progress, concerns and response (Jha, personal communication).

  12. Following up to determine if services are provided and if patient and/or family carries out elements of the plan for which they are responsible.

  13. Documenting the delivery of services provided (MacTaggart, personal communication).

  14. Where necessary, advocating for the patient and/or family in accessing needed services in a preferred manner; resolving problems experienced by patients and providers (Leutz 1999).

  15. Addressing unexpected problems and providing support during crises (Anderson 1996; Patrick, personal communication).

  16. Conducting regular re-assessments of goals, preferences, resources and service needs; adjusting treatment plans accordingly (McManus 1996).

  17. Supporting transitions of patients across providers, facilities, and when necessary MCOs, over time (for example, through the maintenance and with appropriate permission transmission of records) (Devers, personal communication).

  18. Serving as a source of information about persistent problems at the systems level which impede efficient and effective coordination of care for people with disabilities (Ziring, personal communication).

  19. Documentation of corrective actions taken by the MCO with respect to these persistent system-level problems (MacTaggart, personal communication).

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