NAVIGATING THE SPECIAL NEEDS UNIT

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

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Main Components
Physical Health Program
Behavioral Health Program
HealthChoices
Enrollment Assistance Program
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Where are we now?
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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)

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Physical Health Services

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

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MEMBER SERVICES

• Member handbook includes information on
• Services
• Special Needs Units
• Transportation
• Complaints/Grievances/Appeals
• Member hotline
• Member education and outreach
• Coordination of care

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HealthChoices Offers Help to Overcome Obstacles

• Member Services Department
• Special Needs Unit
• PH Plans
• Department
• EAP

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HEALTHCHOICES PHYSICAL HEALTH PLANS

• Southeast
• AmeriChoice Health Plan
• Health Partners Health Plan
• Keystone Mercy Health Plan

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HEALTHCHOICES PHYSICAL HEALTH PLANS

• Southwest
• UPMC for You Health Plan
• Gateway Health Plan
• Unison Health Plan

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HEALTHCHOICES PHYSICAL HEALTH PLANS

• Lehigh Capitol
• AmeriHealth Mercy Health Plan
• Gateway Health Plan
• Unison Health Plan

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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)

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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

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

• ASSIST MEMBERS
• Navigate the Physical Health Managed Care
  Organization (PH-MCO)
• Access Care Coordination
• Access Timely Effective Services

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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

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SPECIAL NEEDS COORDINATION (Examples)

• Behavioral Health MCOs
• Other Physical Health MCOs
• Medical Assistance Transportation Program

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SPECIAL NEEDS COORDINATION (Examples)

• Community Based Agencies
• Public Health Departments
• Consumer Advocacy Groups
• Home and Community Based Services Waivers

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Special Needs Coordination(internally within
PH-MCO)

• UM/QM
• Member Services
• Provider Relations
• Pharmacy Services
• Disease Management

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Special Needs Coordination(external)

• DPWs Special Needs Division
• Other PH-MCO Special Needs Units
• Other state, county and local agencies
• Waiver Providers
• Community Resources

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EXAMPLES OF SNU ACTIVITIES

• Home Visits
• Specialist as PCP Requests
• Individual Case Interagency Meetings including
  IEP development participation

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EXAMPLES OF SNU ACTIVITIES (CONT.)

• 3-Way calls with PCP
• Coordinate with ancillary providers
• Assist with obtaining referrals medical, legal,
  other

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HOW SPECIAL NEEDS UNITS MAKE A DIFFERENCE

• ONE PERSON AT A TIME
• Each special needs members coordination needs
  and challenges are unique and deserve the
  individualized attention necessary to get those
  needs met

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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

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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

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SNU COORDINATORS
Southeast Southwest Lehigh/Capital
AmeriChoice Sarah T. Morvin 1-800-832-4571 Gateway Jeanine Kilgore 1-800-642-3550 Gateway Jeanine Kilgore 1-800-642-3550
Health Partners Shelly Stevens 1-800-553-0784 Unison Demetrios C. Marousis 1-877-844-8844 Unison Demetrios C. Marousis 1-877-844-8844
Keystone Mercy Veronica Medina 1-800-521-6860 UPMC for You Christina Salopek 1-800-286-4242 AmeriHealth Mercy Jared Young 1-888-991-7200
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Southeast Telephone Numbers

• 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

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Southwest Telephone Numbers

• 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

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Lehigh Capital Telephone Numbers

• 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

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RESOURCES

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

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PA Bureau of Fee for Service Programs

• Access Plus- Pennsylvanias 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
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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

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• ACCESS Plus Service areas

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

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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
  recipients needs

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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 (Governors, 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

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CASE MANAGEMENT PROCESS FLOW CHART/WORKSHEET
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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

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Any Questions
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