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

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develop a case management system that includes procedures for assessment and
care planning.
CaIOPTIMA has developed its own case management manual, conducted
workshops for plans and will perform focused case management audits to ensure
that members with special needs are being addressed. Forms and procedures for
making referrals, conducting an assessment and developing a plan of care are
specified in the policy manual. The assessment process evaluates the member's
strengths, problems, prognosis, functional status, needs and short and long term
goals. Information is gathered through phone calls, medical record reviews, multidisciplinary
team meetings, consultation with the primary care physician and
consultation with the utilization review staff. <strong>Care</strong> planning guidelines require that
members be active participants in the process within their capabilities. The manual
also sets parameters for intervention according to "domains." The domains include
medication related issues, health access, safety, treatment/outcomes, and new
onset/diagnosis. Each domain has problem labels, intervention options and
expected outcomes to guide case management activity.
Collaboration with agencies and advocacy is explicitly encouraged. CalOPTIMA
formed a work group to deal with coordination. Issues addressed included dealing
with customized durable medical equipment and approving incontinence supplies.
Plans now approve a six month supply of most supplies but because of changing
eligibility, the supplies are dispensed monthly.
The Arizona Long Term <strong>Care</strong> System
In the Arizona ALTCS program, the role of the case manager is essential in
coordinating delivery of the acute and long term care services and adjusting services
based on health and functional changes. The ALTCS case management manual
describes case management as "the process through which appropriate and cost
effective medical, medically-related social services, and mental health services are
identified, planned, obtained and monitored. The case manager will assist the
individual in maintaining or progressing toward his or her highest functioning
level through the coordination of all services, both formal and informal."
The ALTCS case management manual states that the case manager is responsible for
coordinating services with the primary care physician. The services which case
managers must record in the service plan include institutional services, home and
community based services, behavioral health, durable medical equipment,
medically necessary transportation, therapies, individual/group and/or family
therapies. The manual requires that case managers contact the primary care
physician to discuss changes in the client's condition and to determine whether any
changes are needed in the physician's order concerning the level of care, care plan,
medical services, behavioral health services, prescription drugs or medical
equipment. Case managers use the Preadmission Assessment Survey as a guide in
The National Academy for State Health Policy * 0 8/97 IV-4S