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

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coordinate community supportive and social service systems linkages
with the medical system.
Beneficiaries needing care coordination are identified during the enrollment
process. Enrollment counselors complete a Continuity of <strong>Care</strong> Referral for members
receiving long term care services from the aging network, durable medical
equipment or other services that must be continued. The Continuity of <strong>Care</strong>
Referral is reviewed by the ENCC for potential medical needs and sent to the
primary care physician.
The ENCC role has two dimensions: case management of medical services and
coordination between the medical and social service systems. The medical case
management component covers all services included in the capitation payment and
is designed to assure that "members obtain health care services necessary to
maintain physical and emotional development and health. Medical case
management includes a comprehensive, ongoing assessment of medical and/or
dental needs plus the development and implementation of a plan to obtain needed
medical or dental services that are capitated services or medical case managed
services and follow-up, as appropriate, to assess the impact of care.' 17
ENCC services are available to all <strong>Medicaid</strong> beneficiaries who are elderly, have a
disability, or are children in foster care. ENCC services may be requested by
members, their representatives, a physician or other medical personal, or the
member's long term care system case manager. Some plans also use information
such as hospital admissions to identify those who might need care coordination.
Staff providing ENCC services must have skills and training in the unique needs of
aged, blind and disabled members. Requests must be responded to by the next work
day following the date of the request. Medical practitioners must also be informed
of the availability of ENCC services. Services are also available for members who
exhibit inappropriate, disruptive or threatening behavior in a practitioner's office
when they are related to the member's disability. In most plans, the beneficiary's
primary care physician (PCP) is the focal point for all services.
Plans use ENCCs as a resource to sort issues out and manage the delivery of services.
In one case experienced by Regence HMO Oregon a grandmother in a Cambodian
family who had a stroke and received ventilator care was being cared for at home by
her daughter. The daughter attempted to order a hospital bed, a hoyer lift, a
specialty chair, and IV equipment. In addition, she took supplies from the hospital
at discharge and ordered excessive supplies from providers. The ENCC convened a
meeting with the daughter, the long term care case manager, the home health
agency, and the respiratory therapy agency. They agreed on one supplier and the
17 Oregon Health Plan Administrative Rules, 410-141-000.
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