Traumatic Brain Injury Advisor Board Presentation: Case Management within PA Medicaid

1. Traumatic Brain Injury Advisor Board Presentation: Case Management within PA Medicaid September 04, 2008

2. PA Mandatory Managed Care Medicaid Program (HealthChoices) AND THE SPECIAL NEEDS UNITS Eric D. Ulsh Human Services Program Specialist Department of Public Welfare Office of Medical Assistance Bureau of Managed Care Operations Division of Quality and Special Needs Coordination

3. Main Components Physical Health Program Behavioral Health Program HealthChoices Enrollment Assistance Program

4. SW: 1999 L/C: 2002 SE: 1997 Where are we now?

5. Physical Health Choice of Physical Health Plans Choices of doctor (PCP = Primary Care Physician or Practitioner) Same service coverage as available under MA FFS Program. (Based on Category of Assistance)

6. Physical Health Services • Outpatient Hospital • Inpatient Hospital • Dental, Vision • Physician Services (including OB/GYN) • Medical Equipment • Diagnostic Services • Home Health • Prescriptions

7. MEMBER SERVICES • Member handbook includes information on: • Services • Special Needs Units • Transportation • Complaints/Grievances/Appeals • Member hotline • Member education and outreach • Coordination of care 46

8. HealthChoices Offers Help to Overcome Obstacles • Member Services Department • Special Needs Unit • PH Plans • Department • EAP

9. HEALTHCHOICES PHYSICAL HEALTH PLANS • Southeast • AmeriChoice Health Plan • Health Partners Health Plan • Keystone Mercy Health Plan

10. HEALTHCHOICES PHYSICAL HEALTH PLANS • Southwest • UPMC for You Health Plan • Gateway Health Plan • Unison Health Plan

11. HEALTHCHOICES PHYSICAL HEALTH PLANS • Lehigh Capitol • AmeriHealth Mercy Health Plan • Gateway Health Plan • Unison Health Plan

12. HealthChoices Program Design • Inclusion of persons with special needs • Created Special Needs Component • Enrollment Assistance Program (EAP) for enrollment and Managed Care Organization (Plan) changes • Each Physical Health - Managed Care Organization (PH-MCO)

13. SPECIAL NEEDS UNITS • Each Physical Health Managed Care Organization (PH-MCO) has one • Special Needs Unit Coordinator/Director • Has direct contact with the Medical Director at the PH-MCO • Qualifications include multiple years experience with Special Needs Populations

14. DEFINITION OF A SPECIAL NEED * non-categorical Anyone who thinks they have a special need can be referred to the special needs unit Examples of a special need: Short term HIV/AIDS Long term Brain Injury Mental Retardation Social Issues Pregnant Women Behavioral Health Coordination

15. COORDINATION OF CARE PCP Advocate Family Member HEALTH PLAN (MCO) SPECIAL NEEDS UNIT Community Agency Community Service

16. SPECIAL NEEDS UNITS • ASSIST MEMBERS: • Navigate the Physical Health Managed Care Organization (PH-MCO) • Access Care Coordination • Access Timely & Effective Services

17. SPECIAL NEEDS UNITS • HELP THE MEMBER TO: • Assist in selection of a Primary Care Physician (PCP) • Assist in identifying non-MA Resources • Assist with complaint and grievance procedure • Transition to Waiver services

18. SPECIAL NEEDSCOORDINATION (Examples) • Behavioral Health MCOs • Other Physical Health MCOs • Medical Assistance Transportation Program

19. SPECIAL NEEDS COORDINATION (Examples) • Community Based Agencies • Public Health Departments • Consumer Advocacy Groups • Home and Community Based Services Waivers

20. Special Needs Coordination(internally within PH-MCO) • UM/QM • Member Services • Provider Relations • Pharmacy Services • Disease Management

21. Special Needs Coordination(external) • DPW’s Special Needs Division • Other PH-MCO Special Needs Units • Other state, county and local agencies • Waiver Providers • Community Resources

22. EXAMPLES OF SNU ACTIVITIES • Home Visits • Specialist as PCP Requests • Individual Case “Interagency” Meetings including IEP development participation

23. EXAMPLES OF SNU ACTIVITIES (CONT.) • 3-Way calls with PCP • Coordinate with ancillary providers • Assist with obtaining referrals – medical, legal, other

24. HOW SPECIAL NEEDS UNITS MAKE A DIFFERENCE • ONE PERSON AT A TIME • Each special needs member’s coordination needs and challenges are unique and deserve the individualized attention necessary to get those needs met

25. SND/COMMCARE Coordination Process Identify COMMCARE Member to PH-MCO Identify Service Coordinator to PH-MCO SNUC outreaches and establishes communication link with Service Coordinator

26. SND/COMMCARE Coordination Objectives • Prevent duplication of services • Serve as a resource for resolution of PH service concerns • Assist in coordination with BH-MCO • Identify other community resources for necessary services not covered under the State plan or the COMMCARE Waiver

27. SNU COORDINATORS

28. Member Services AmeriChoice 1-800-321-4462 TTY 1-800-654-5984 Health Partners 1-800-553-0784 TTY 215-849-1579 Keystone Mercy 1-800-521-6860 TTY 1-800-684-5505 Special Needs Units AmeriChoice 215-832-4571 TTY 1-800-654-5984 Health Partners 215-991-4370 TTY 215-849-1579 Keystone Mercy 1-800-521-6860 TTY 1-800-684-5505 Southeast Telephone Numbers

29. Member Services UPMC for You, Inc. 1-800-286-4242 TTY 1-800-361-2629 Gateway Health Plan 1-800-392-1147 TTY 1-800-654-5988 Unison 1-800-414-9025 TTY 1-888-616-0071 Special Needs Units UPMC for You, Inc. 1-800-286-4242 TTY 1-800-361-2629 Gateway Health Plan 1-800-642-3550 TTY 1-800-654-5988 Unison 1-877-844-8844 TTY 1-800-473-0989 Southwest Telephone Numbers

30. Member Services AmeriHealth Mercy 1-888-991-7200 TTY 1-888-987-5704 Gateway 1-800-392-1147 TTY 1-800-654-5988 Unison 1-800-414-9025 TTY 1-888-616-0021 Special Needs Units AmeriHealth Mercy 1-888-991-7200 TTY 1-888-987-5704 Gateway 1-800-642-3550 TTY 1-800-654-5988 Unison 1-877-844-8844 TTY 1-888-616-0021 Lehigh Capital Telephone Numbers

31. RESOURCES Department of Public Welfare website: www.dpw.state.pa.us Phone Us Managed Care Operations, Special Needs Division 717-705-8220

32. PA Bureau of Fee for Service Programs • Access Plus- Pennsylvania’s Enhanced Primary Care Case Management (EPCCM) program that operates in the 42 counties where HealthChoices is not operational by the Department of Public Welfare Jean Whitehead, RN,CCM Clinical management Consultant Department of Public Welfare Office of Medical Assistance Programs Bureau of Fee for Service Programs

33. Components of ACCESS Plus • Physical Health Services – provided, coordinated and managed by PCPs. • Intense Medical Case Management- provided by Department of Public Welfare • Disease Management Services – provided by the ACCESS Plus contractor and includes the following conditions: • Asthma • Diabetes • Chronic Obstructive Pulmonary Disease • Coronary Artery Disease • Congestive Heart Failure • Care Coordination Services – provided by the ACCESS Plus contractor • Enrollment Assistance Services – provided by the Enrollment Assistance Program contractor

34. ACCESS Plus Service areas

35. CASE MANAGEMENT MODEL Community assessment Recipient & Care manager advocacy planning facilitation Payer Healthcare team

36. OVERVIEWUNIT STRUCTURE • 27 nurse case managers (17 general, 6 high risk OB, 2 high risk neonate,1 behavioral health care liaison, 1 supervisor) • Nurse case managers: generalists & specialists, provide medical care management services to all age groups & medical diagnoses • Model: telephonic medical case management; in-home visits made on a case by case basis • Referral sources: medical directors, prior authorization unit, inpatient & special procedure unit, pharmacy unit, McKesson disease case managers, AHS care coordinators, legislative affairs, legal affairs, secretary & deputy secretary's office, physicians, Predictive Modeling, others • Referrals are submitted to a designated care manager for initial review and assigned as appropriate • Case manager assigned performs a comprehensive assessment

37. OBJECTIVES OF CASE MANAGEMENT UNIT • Provide care management services, assuring continuity of care and follow up • Provide comprehensive assessment of medical, social and psychosocial needs • Develop of plan of care addressing clinical care/services, social and psychosocial needs • Provide assistance in coordinating multidisciplinary health care services and referral activities, to minimize duplication of services • Provide ongoing follow-up activities to ensure delivery of needed health care and social services • Provide periodic reassessment and evaluation of recipient needs and care management activities • Collaborate with physicians, specialists and other medical professionals to meet the recipient’s needs

38. CRITERIA FOR CASE MANAGEMENT INTERVENTION(potential candidates) • Amputations (post-op, rehab phase & new prosthesis) • Burns • Complex medical/surgical issues • Complex wound care • Congenital anomalies (care required during the first 12 months) • Coordination of care • DME/ med supply issues • High profile issues (Governor’s, Deputy Secretary ‘s and/or legislative affairs office) • High risk maternity management • High risk mental health with physical health co morbidities • High risk neonates • High utilization of home health services • HIV/AIDS • Multiple in-patient admissions (four (4) within a six (6) month period) • Out of State services/ placement • Poor prognosis (6-12 months) with potential end of life planning needs/Hospice • Pain Management • Residential treatment facility monitoring • Spinal cord injury • Transplant candidates, organ • Traumatic brain injury • Vent/tech dependent • Other referrals, as appropriate

39. CASE MANAGEMENT PROCESS FLOW CHART/WORKSHEET

40. Contact Information • Intense Medical Case Management Unit • Jean Whitehead 717-772-6777 • Mallie Carter 717-772-6782 • Joanne MacCollum or Nancy Snyder 717-772-6048

41. Any Questions

42. THANK YOU! 49