Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 6.4. Care Coordination Through Managed Care Organizations


Managed care plans must either deliver care coordination services to their members or contract with other organizations to do so. By care coordination, we mean the health assessment and care management needed by people to address multiple behavioral and physical health needs. This section describes some of the challenges that managed care plans have encountered in serving seniors and persons with disabilities and how those challenges have been overcome.

For those identified as needing care coordination, services may include arranging for specialty care, home health services, and medical equipment such as wheelchairs. Care managers also sometimes provide case management--for example, information about transportation assistance, food programs, and other social services. To the extent the care managers know about housing and shelter options for homeless members, they provide information about them. In Los Angeles, nearly all of these care management services are delivered by telephone, and this is the approach typically used by MCOs. Less frequently, health plans have nurse care managers, social workers, case managers, or patient navigators who deliver face-to-face services to some members who have been identified as "high-risk" because of diagnostic or claims data, including patterns of using hospitals or pharmacy services.

In Los Angeles, LA Care's existing systems of risk assessment and care management had limited capacity to engage and provide the intensive support needed for people with complex health problems and chronic patterns of homelessness. Health risk assessment forms are mailed to individuals upon enrollment into managed care, and LA Care staff attempt to reach people by telephone to complete the assessments. However, response rates are very low. Care management may be offered to a member only if the health assessment is completed and the member is identified as high-risk or if needs are identified at the time of discharge from an inpatient hospitalization or based on other health service utilization data. When a patient is discharged from a hospital, the plan makes three attempts to contact him or her by telephone or mail. Many plan members do not respond to mail or telephone contacts or cannot be reached using the available contact information. Thus LA Care's standard approach is unlikely to identify plan members who are experiencing chronic homelessness or to engage and deliver ongoing care management services to them.

At the time of our visits, very little coordination or information sharing occurred between the care management services offered by Medicaid managed care plans such as LA Care and the services and supports available from the county mental health system for members who have serious mental illness, including PSH and the supportive services that go with it. As the state prepared to implement a demonstration initiative to coordinate care for people who are eligible for benefits through both Medicaid and Medicare, efforts were under way to improve coordination and communication among California's Medicaid managed care plans, including LA Care and county systems responsible for mental health and substance use disorder services.

In Minnesota, the Special Needs Basic Care plans that have enrolled Medicaid seniors and persons with disabilities are responsible for completing comprehensive health assessments and providing care coordination services to help patients get the care they need from primary care providers, specialists, and other health care services. The plans are also responsible for a benefit package that includes targeted case management services for people with serious mental illness.

Some of the Special Needs Basic Care plans have worked with mental health service providers, including those who deliver services in PSH, establishing contracts and sharing training and other resources. The TCM providers also deliver some of the care management services that the health plan's nurse care managers might otherwise do. To build their capacity to deliver this broader scope of services, the mental health service provider organizations have added nurses to their case management teams, trained staff to conduct more comprehensive health assessments, and implemented electronic health records that integrate some medical and behavioral health information. As their roles expand from case management to care management, many staff members must acquire new skills.

  • For example, Guild, Inc. is a mental health and PSH provider organization that has made a significant investment and organizational commitment to staff training and change management. The organization adjusted its electronic health record system to prompt case managers to ask questions about physical health when they meet with clients. In 2010, staff began to get baseline data on some health indicators, and by the end of 2011 the data showed a big increase in the number of mental health clients who have seen their primary care providers and had physical exams.

One of the Special Needs Basic Care health plans, Medica, provides care management services using a combination of staff (social workers, nurses, and nurse-practitioners) and vendors or partner organizations, including the mental health providers who deliver TCM services in PSH. Medica care coordinators do home visits for some members, in addition to providing services by telephone. Medica care management tools (such as assessment instruments, care plans, and information systems) are shared with the plan's vendors. Medica recognizes that some of these partner organizations have a background in social services but less capacity or experience with medical issues. The Medica nurses and nurse-practitioners are available to these partners to provide clinical consultations or do home visits as needed.

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