Case Manager: Personal Care Attendant (PCA) Learning Module

1. Case Manager: Personal Care Attendant (PCA) Learning Module BCBS Secure Blue--MSHO BluePlus PMAP MN Senior Care Presented by Annette Sietsema, RN, BAN Kandiyohi County Public Health Nurse/Case Manager For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006

2. BCBS Members Affected BluePlus PMAP Members (population under age 65) Minnesota Senior Care (PMAP over age 65) Secure Blue Members Kandiyohi County Public Health & Kandiyohi County Family Services

3. Legislative (2005) Changes to the PCA Program A “Statement of Need” for PCA services “PCA Flexible Use Agreement” New documentation requirements* PCA individual provider numbers required* *The CM does not facilitate these areas Kandiyohi County Public Health & Kandiyohi County Family Services

4. PCA Referral Process Each program is slightly different. It is the FIRST step of each plan that is unique in its application. All subsequent steps for each plan are identical thereafter. Kandiyohi County Public Health & Kandiyohi County Family Services

5. It all begins with a phone call… • Who yougonna’ call? • No not the Ghost Busters • In fact YOU don’t have to call anyone • It is now the responsibility of the PCA Provider to make the first contact Kandiyohi County Public Health & Kandiyohi County Family Services

6. So who does the PCA provider call? It is different for each type of BCBS plan… Does the provider know that they need to make the first call? Does the provider know who they have to call? “I’m the case manager what am I suppose to do?” Kandiyohi County Public Health & Kandiyohi County Family Services

7. Your new titles will be: EducatorAdvocateCollaborator "Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination.“ http://www.acmaweb.org Kandiyohi County Public Health & Kandiyohi County Family Services

8. Educating the Provider You will play an important role in facilitating the initiation of PCA services for your clients. Much of what you will be doing will support and educate providers as we all begin this new (and somewhat cumbersome) process. Kandiyohi County Public Health & Kandiyohi County Family Services

9. STEP #1 We will examine Step #1 of each program separately (With great anticipation & bated breath…) Kandiyohi County Public Health & Kandiyohi County Family Services

10. Step #1: Blue Plus PMAP PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s individual case manager: CALL: 651-662-5520 1-888-878-0139 Kandiyohi County Public Health & Kandiyohi County Family Services

11. Step #1: MN Senior Care PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s individual case manager. CALL SENIOR PUBLIC PROGRAMS INTAKE @ 651-662-5540 1-800-711-9868 Kandiyohi County Public Health & Kandiyohi County Family Services

12. Step #1: Secure Blue--MSHO PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s County Care Coordinator. If the PROVIDER does not know who the County CM is they may contact Sr. Public Programs Intake for assistance in locating the member’s county care coordinator. CALL SENIOR PUBLIC PROGRAMS INTAKE @ 651-662-5540 1-800-711-9868 Kandiyohi County Public Health & Kandiyohi County Family Services

13. Steps Two, Three, Four & Five For all three BCBS programs the subsequent steps are identical... Kandiyohi County Public Health & Kandiyohi County Family Services

14. Step #2 An assessment of the member’s need for PCA services will be completed by a PHN, EW Case Manager or County Care Coordinator. Kandiyohi County Public Health & Kandiyohi County Family Services

15. Step #3 A BCBS Case Manager (not us!) will submit the Statement of Need to the member’s primary care clinic after the assessment has been completed. Kandiyohi County Public Health & Kandiyohi County Family Services

16. Step #4 The members primary care provider will review and order PCA services (a Nurse Practitioner is also qualified to do this) The practitioner is to return the form to BCBS within 24 hours. Kandiyohi County Public Health & Kandiyohi County Family Services

17. Step #5 The BCBS Case Manager will forward a copy of the completed Statement of Need with the determination letter issued to the PCA provider and the member Kandiyohi County Public Health & Kandiyohi County Family Services

18. A closer look…at Secure Blue/MSHO The County Care Manager (us) responsibility once the Provider has requested PCA services…. Verify the need—you may need to make a home visit Call Secure Blue (Bobbi Cooper) Remind the PCA agency about the new process for PCA authorization of need Update the CSP and fax to Secure Blue Discuss “Flexible Use” option with client and fax completed form to Secure Blue—remember to obtain signature (if BCBS does not receive the form they will assume that the PCA hours will be flexed month to month. Kandiyohi County Public Health & Kandiyohi County Family Services

19. Flexible Use Option http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf Kandiyohi County Public Health & Kandiyohi County Family Services

20. A few words from Deb Floren Kandiyohi County Public Health & Kandiyohi County Family Services

21. Questions/Comments Are we in love yet?... Kandiyohi County Public Health & Kandiyohi County Family Services

22. Closing Thoughts Any fool can make things bigger, more complex and more violent. It takes a touch of genius—and a lot of courage—to move in the opposite direction. ~Albert Einstein Kandiyohi County Public Health & Kandiyohi County Family Services

23. Reference BCBS (2006). Legislative changes to PCA program. BCBS Provider Bulletin. As found at: http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf Kandiyohi County Public Health & Kandiyohi County Family Services