Emerging Practices in Medicaid Primary Care Case Management Programs. Care Coordination


Several case-study states have designated care coordinators to assist Medicaid beneficiaries in PCCM programs. North Carolina officials reported that care management, targeted appropriately, has been critical to the success of ACCESS II and III. Many networks have hired their own care managers and developed individual care management initiatives. PCPs appreciate the functions undertaken by care coordinators, including conducting health needs assessments with all new members. For example, care coordinators in sites participating in the asthma disease management initiative35 have

  • implemented a screening process to identify those members who would most benefit from case management;
  • reinforced compliance in managing asthma;
  • performed home visits for environmental assessments and patient education;
  • provided outreach and follow-up for PCP visits for checking compliance with home monitoring;
  • managed and coordinated referrals;
  • educated provider staff and implemented educational activities within the PCP's practice; and
  • assisted individual practices in implementing quality improvement activities.36

Oklahoma has three Exceptional Need Coordinators (ENCs) serving all Aged/Blind/Disabled Medicaid beneficiaries in PCCM in rural areas. The state is currently seeking to hire one more ENC and also mandates MCOs to employ ENCs in contract requirements. Two ENCs are RNs and the other is a social worker with extensive field experience; state officials are pleased with the combination of skills embodied in these three individuals. ENCs primarily serve Medicaid beneficiaries in PCCM or fee-for-service but also assist the ENCs within MCOs, as needed. PCPs call the state provider representative for their area in order to initiate contact with the ENCs; members can self-refer, or PCPs can call ENCs directly.

In Texas, regional case managers employed by the plan administrator coordinate medical care (working with the PCP) and non-medical care for certain PCCM members. These workers link with health-related and socioeconomic community resources, working from community-specific information-and-referral databases that can be accessed through the state's web site. Case management staff, employed by the plan administrator, coordinate care for members who meet certain criteria.

Iowa has 250 providers enrolled in a program in which they receive a periodic list of their members who are due for immunizations and EPSDT screening examinations. The Department of Human Services contracts with the Department of Public Health to provide such notification to all other PCCM members.

MaineNET's Partnership program serves people who are eligible to receive long-term care services in the community. Upon voluntarily joining the program, these individuals work with a care coordination organization and the PCP to develop a care plan for long-term care services, including necessary social and community services. An employee of the care coordination organization, typically an RN or LSW, is located in the PCP's office. While members do have a choice of PCP, they work with the care coordinator assigned to that PCP's office. The care coordinator works with the member and PCP to implement the care plan through telephone coordination and in-home case management, coordinating services among providers as needed, as well as administering yearly risk screens. The care coordinator also serves as a resource to the PCP and staff, sharing knowledge of long-term care programs and informal services available. The PCP continues to provide primary and acute services and collaborates with the care coordinator on the care plan as necessary; the care coordinator may even attend office visits with the approval of both the PCP and the member. Average caseload per care coordinator is 50-60 clients; potential practice sites are considered for inclusion in the program if their practices have at least 50 potential Partnership clients who would support a full-time care coordinator. The state is currently developing performance measures for the care coordination piece of this program.

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