Emerging Practices in Medicaid Primary Care Case Management Programs. Health Needs Assessments


In Maine, MaineNET and Partnership staff perform initial and annual assessments on each member. Initial assessments use the PraPlus tool34, designed to identify people at high risk of hospitalizations unless they obtain additional medical or social support services to lower their risk, as well as to identify needs for cognitive or dementia follow-up. The questionnaire is completed over the phone with the member by the enrollment broker for MaineNET members and the care coordinator for Partnership members. The enrollment broker reviews all questionnaires and calculates a score, which is relayed to the PCP. MaineNET developed its Periodic Preventive Screen with recommendations taken from the U.S. Preventive Task Force. It includes questions on level of function, need for assistance, current service utilization, medical history, preventive screens and immunizations, and follow-up needs. PCPs or care coordinators are to conduct this assessment with each member at least annually; a copy is sent to the state, as well as kept in the medical record.

ACCESS II and III sites in North Carolina complete health needs assessments on all new members. These are frequently completed by care coordinators working with members. Oklahoma has also implemented health needs assessments to better coordinate care for newly enrolled ABD beneficiaries (as referenced in the Quality Improvement section, earlier in this report).

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