Medicaid Managed Care - U.S. Senate Special Committee on Aging

544
<strong>Care</strong> Coordination Process
Under a demonstration program proposed by the Massachusetts Division of Medical
Assistance, Senior <strong>Care</strong> Organizations will form primary care teams consisting of a
primary care physician, a nurse practitioner or registered nurse and a geriatric
services coordinator (GSC). The GSC would be a staff of the existing community
long term care system or Aging Services Access Points. 16 Beneficiaries identified as
at risk during an initial assessment would receive a comprehensive geriatric
assessment, including an in-home assessment by the team.
Senior <strong>Care</strong> Organization contractors would be responsible for ensuring linkages
among all subcontractors (acute, specialty, mental health/substance abuse and long
term care). In addition a process for making referrals, recording and tracking the
results of referrals, sharing clinical information, tracking enrollee transfers from
settings and a centralized enrollee record will be required.
Plans in California and Tennessee have developed procedures to identify risk and
devise care coordination plans even though they are not required by state contracts.
Coordination in these plans extends beyond referrals from primary care physicians
to specialists and includes making sure durable medical equipment and supplies are
available, appointments and treatment plans involving physicians and home
health services are coordinated, assessments are performed and treatment plans are
modified as appropriate. Coordination also means working with hospital discharge
planners, therapists and home health providers as well as case managers and
providers in the community based services programs.
Exceptional Needs <strong>Care</strong> Coordinator-Oregon
The Oregon Health Plan has perhaps the most defined care coordination service.
Health plans are required to create Exceptional Needs <strong>Care</strong> Coordinator (ENCC)
positions. Plans indicated that they were very actively involved in developing the
role and function of the position. ENCC services are designed to:
* identify members who have disabilities or complex medical needs;
* provide assistance to ensure timely access to providers and capitated
services;
* coordinate services with providers to ensure consideration is given to
the unique needs in treatment planning;
* assist providers with coordination and discharge planning; and
16 Aging Services Access Points, formerly Home <strong>Care</strong> Corporations, are non-profit
community-based organizations a majority of whose board members are over 60 years of age. Many of the
State's corporations also serve as Area Agencies on Aging (AAAs).
The National Academy for State Health Policy * @ 8/97
IV-41