Care coordination is the back-bone of member safeguards. Care coordinators are the system's eyes and ears for ensuring the well-being of members. They help the individual devise a service/support plan that is intended to meet their unmet needs, minimize risk, maintain health/function, and provide quality of life. Following the service initiation, it is then incumbent on the care coordinator to monitor the member's receipt of services as well as any circumstances that signal a need for a change in the plan (e.g., health change, mental health crises, change in the informal support system, increased risk taking, etc.) thereby minimizing the member's exposure to risk and consequent threats to health, functioning or quality of life. Assisting the person with coordination of acute care and behavioral health needs also falls to the care coordinator, as well as assistance with transitions related to hospitalizations and institutional care.
i. Required Contacts with Members
Given the importance of care coordinator contacts with members, we included this element in our case studies. Among the study states, contract frequency ranges from discretion of the MCO, to some combination of MCO discretion and required frequency of contracts, to prescribed frequency. A breakdown of these approaches is provided in Exhibit 6.
|EXHIBIT 6. Frequency of MCO Care Coordinator Contacts|
|AZ||Semi-annually: members in nursing facilities
Quarterly: community-based members
|MI||Determined by need|
|TN||Annually: >21 in nursing homes
Quarterly: <21 in nursing homes
Monthly contacts, quarterly in-person: nursing home level of care living in the community
Quarterly contacts, in-person annually: at risk of nursing home absent HCBS
|WI||Quarterly contacts for the first 6 months
After 6 months, MCO discretion
Both Michigan and North Carolina serve persons with mental illness and SUDs, as well as the IDD populations. North Carolina's newer program is modeled on Michigan's longstanding program and thus it is not surprising that their requirements are somewhat similar (no requirement and determined by need, respectively). In our interviews with state officials they noted that the care coordination needs for the mentally ill population is very different than for IDD members. The IDD population uses care coordination on a routine basis whereas members with mental illness use it only sporadically since their main support comes from mental health counselors and peers. When the mental illness population does utilize care coordination, it is typically for assistance with housing or other social services.
Wisconsin requires quarterly contacts for the first six months, and subsequently leaves it to the MCO to determine how frequently a given member needs to be contacted (but with a minimum of a yearly contact). By six months it is assumed that a relationship has been established between the member and the care coordinator and that the care coordinator can best determine how often contact is needed.
There is also variability around whether contacts must be conducted face-to-face, on the phone, or even by mail. For example, Texas allows any type of contact, whereas most of the other programs specify in-person. The exception is Tennessee which allows some contacts by phone as noted above.
ii. Care Coordination Ratios
Four out of the eight study states do not specify any care coordination ratios. Only Arizona has absolute maximum ratios and uses a weighting scheme that accounts for the case-mix of the care coordinator's caseload (i.e., HCBS, nursing facility, assisted living).
The MCOs in Minnesota must submit their ratio policies to the state for review. If the MCOs ratios in Wisconsin vary from state norms, then the state may ask the MCO to justify its ratios. Tennessee recommends maximum ratios, but does not mandate them. However, if the MCO is found out-of-compliance with any care coordination contractual requirements and its ratios exceed that which the state has recommended, it is assessed liquidated damages.
iii. Evolution of Care Coordination
It is always instructive to learn from states how their programs develop and change over time. Arizona told us that they discovered that when a member moved from one MCO to another, care plans and service authorizations often changed as a result of the MCOs using their own assessment instruments. For reasons of equity, the state decided to mandate a uniform assessment which has resulted in more consistency across the MCOs in service planning and authorizations. Arizona's move to a uniform assessment is consistent with emerging consensus that a uniform assessment instrument is best practice and something CMS is now requiring for states participating in the Balancing Incentives Program.21
At the time of our interview, Texas was on the cusp of becoming more prescriptive in its requirements for care coordinator contacts with members due to a stakeholder feedback and a resulting legislative mandate. They were moving from two member contacts per year where it was the discretion of the MCO how to make the contact (in-person, phone, mail) to a system based on the member's acuity and risk levels with prescribed modes of contact for each level. For example, those at highest risk will receive two face-to-face visits per year by an assigned (consistent) care coordinator while those at lowest risk will receive two phone contacts per year by any care coordinator.
During interviews we also inquired about any instances of tension between care coordinators and MCO staff responsible for authorizing services. Both state and MCO staff in Michigan mentioned that care coordinators had been frustrated at an earlier point in time about service denials by the MCO's utilization management. Apparently the cause of many denials was inadequate documentation by care coordinators, which was subsequently addressed, and tension between the two had dissipated. In the discussion of this topic, both state officials and the MCO wanted it understood that in Michigan the MCOs (technically PIHPs), are non-profit entities (Community Mental Health Service Programs) and as such there was not profit motive or incentive to limit member utilization. Our discussions with North Carolina reported little tension between care coordinators and those authorizing services. The North Carolina program also serves members through non-profit MCOs, and they too mentioned that there was no financial motive for restricting services.
While Pennsylvania officials did not voice any current concern about care coordinator conflicts with the MCOs utilization management, they did mention that when the program was being developed that consumers and advocates were anxious that services would be reduced under managed care. The state tried to reframe the issue by focusing on the care coordinator's role to increase member independence with care coordinator support. Members' and advocates' initial concern have not resurfaced since program implementation.