Care Coordination for Medicaid ... - Magellan Of Virginia · Magellan is currently administering a...

Care Coordination for Medicaid Members in Virginia

Presented by:

Ashley Locher, LPC, Lead Care Manager and

Malinda Tiffany, LCSW, Clinical Quality Liaison

May 2016

What is Care Coordination?

Care coordination means a collaboration and sharing of information among health care providers, who are involved with an individual’s health care, to improve care. [CMHRS

Manual chap IV page 10]

The purpose of Care Coordination is to ensure that the member receives all needed services and supports; that these resources are well-coordinated and integrated; and that they are provided in the most effective and efficient manner possible.

For a member receiving Community Mental Health and Rehabilitative (CMHR) services, this activity is meant to ensure an optimal Individual Service Plan is developed based on as much information as possible related to both the member's physical and behavioral clinical presentation. Care coordination between different providers is required and must be documented in the ISP and Progress Notes. Care Coordination serves to help align services to prevent duplication and is intended to complement the service planning and delivery efforts of each service.

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Service Provider Care Coordination

"Care coordination“ as defined in 12VAC30-50-130, means the same as Service Coordination defined in the DMAS manual as collaboration and sharing of information among health care providers who are involved with an individual's health care to improve the care. Service Provider Care Coordination is done in the spirit of collaboration

with the treatment team and is meant to support the member on his or

her path of recovery.

Service Provider Care Coordination includes: • Assisting the member to access and appropriately utilize needed services and supports; • Assisting members to overcome barriers to being able to maximize the use of these resources; • Actively collaborating with all internal and external service providers; • Coordinating the services and supports provided by these members (including family members and significant others involved in the member’s life); • Assessing the effectiveness of these services/supports; • Preventing duplication of services or the provision of unnecessary interventions and supports; and • Revising the service plan as clinically indicated and to ensure that service planning is consistent with other services being provided to the member.


Service Coordination and Continuity of Care

Service Coordination: All ISPs should clearly include service coordination as necessary toward the attainment of the objective. Service coordination activities must be related to the specific treatment needs and the related service goals and objectives of the member. They must include and describe any psycho-educational or service coordination strategies related to other care providers and persons (other CMHRS services, Outpatient/Clinic Services, Foster Care, Judicial or Educational related staff, Relatives, etc.) who routinely come in contact with the member.

Continuity of Care: All ISPs should clearly identify all current professionals involved in the member’s care and document active coordination during the duration of the service (i.e. educational, psychiatric, medical, case management, probation, etc.)


DMAS and Magellan’s agreement on Care Coordination Magellan is currently administering a coordinated care model for behavioral health services for Virginia Medicaid and FAMIS members, and is working diligently to improve access to quality behavioral health services and improve health outcomes for our members.

DMAS and Magellan of Virginia agree that care coordination has two (2) main goals:

1) to improve the health and wellness of members with complex and special needs; and 2) to integrate services around the needs of the member at the local level by working collaboratively with all partners, including the individual, family and providers.


Why is Magellan passionate about this? Care coordination is an essential part of transforming total care. By overseeing all of a member’s care services and needs and enabling communication among the service providers, we are able to coordinate the delivery of diverse yet integrated services and allow the member to achieve safer and more effective care.

Through care coordination, we are able to empower members to be active participants in their treatment process and have a voice in their personal recovery.

A growing body of evidence suggests that care coordination improves access to the appropriate treatment services, improves the quality of care, enhances member satisfaction with the services received, increases positive treatment

outcomes, and decreases the use of costly and, often,

inappropriate services.


Current examples of Magellan Care Coordination activities

• For any member enrolled in GAP case management with a Community Services Board [CSB] there are requirements for care coordination between the CSB Case Manager and Magellan GAP Care Manager. This activity is meant to ensure an optimal Individual Service Plan [ISP] be developed based on as much information as possible related to both the member’s physical and behavioral clinical picture. [March 6, 2015 Provider Notice]

• As part of a quality improvement activity focused on improving care coordination between TDT and IIH providers who are treating the same members, a Magellan Care Manager may contact a TDT or IIH provider to discuss care coordination when it is recognized that a member being treated is receiving both TDT and IIH services. [July 7,

2015 Provider Notice]

• Questions added to the Psychosocial Rehabilitation Service Request Authorization [SRA] form asking for the contact information of CSB Case Managers in order to increase coordination of care between Magellan Care Managers and CSB Case Managers. [March 14, 2016 Provider Notice]


Coordination of Care with Magellan Care Managers

•Care Managers complete regular outreach activities to partner with providers regarding Service Request Authorizations [SRA] submissions and clinical information submitted.

•Some areas of care coordination that Magellan collaborates with providers about are accessing higher and lower levels of care, medical necessity criteria and other information to improve the health and wellness of members.

•The recommendations made by Magellan care managers are based on information submitted regarding clinical presentation of member and current services the member is receiving.

•Providers are encouraged to document any referrals made to other levels of care and explain why a referral was or was not made or followed through with at the next SRA request.


Examples of CMHR Services that require Care/Service Coordination

•Intensive Community Treatment (H0039) [CMHRS manual Chap IV page 59]

• The purpose of ICT Service Coordination is to ensure that the individual receives all

needed services and supports; that these resources are well-coordinated and integrated; and that they are provided in the most effective and efficient manner possible.

• ICT Service Coordination includes assisting the individual to access and appropriately

utilize needed services and supports; assisting them to overcome barriers to being able

to maximize the use of these resources; actively collaborating with all internal and

external service providers; coordinating the services and supports provided by these

individuals ; assessing the effectiveness of these services/supports; preventing duplication of services or the provision of unneeded

interventions; and revising the service plan as clinically

indicated.


Examples of CMHR Services that require Care/Service Coordination [cont.]

•Residential Level A and B (H2022 and H2020)[CMHRS manual Chap IV pages 39 and 47)

•If a member is receiving case management services while in residential levels A or B programs, the provider must collaborate with the case manager by notifying the case manager of the provision of services and send written monthly updates on the member’s progress. A written discharge summary must be sent when the service is discontinued.

•Crisis Intervention (H0036) [CMHRS manual Chap IV page 55]

•Providing access to further immediate assessment and follow-up services;

•Service Coordination to include linking the individual and family with ongoing care to prevent future crises.

•Mental Health Skill Building Services (H0046) [CMHRS manual Chap IV page 63]

•The LMHP, QMHP-A or QMHP-C shall coordinate care with the prescribing physician regarding any medication regimen non-adherence concerns.


Discharge Planning and Service Coordination

•Per Magellan Medical Necessity Criteria for Inpatient Hospitalization, “if the patient is involved in treatment with another health provider, then, with proper patient informed consent, this provider should be notified of the patient’s current status to ensure care is coordinated”. •Also as noted in the Psychiatric Services manual, in regards to Inpatient Psychiatric Residential Treatment Services, [Chap IV page 15], “Active treatment and comprehensive discharge planning for aftercare placement and treatment must begin at admission. A lack of family or guardian involvement in discharge planning does not mean that discharge planning is not conducted. Discharge planning, at a minimum, should be an on-going discussion with the individual about managing symptoms, accessing and using resources, etc upon discharge. “ •When discharging a member from any level of care to a less restrictive level of care, providers are encouraged to coordinate with other providers about services available to support the member at discharge and during the transition in services. •This would typically involve sharing information between providers prior to member transitioning to the lower levels of care. This may also involve some brief follow up by the initial provider to insure the discharge/transition in services has been successful for the member.


Care Management services

Care Management is provided by Magellan employed clinical staff who are licensed behavioral health clinicians.

The central purpose of Care Management is to help individuals receive quality services in the most cost-effective manner. The primary activities of care management include utilization management, triage and referral, opening communication between identified providers, aligning care plans, discharge planning following 24 hours levels of care, continuity of care, care transition, quality management, and independent review.

Through the care management process, Magellan assists members in optimizing their benefits by reviewing and authorizing appropriate services to meet their behavioral healthcare needs in a timely manner.

Magellan manages care in accordance with the requirements,

allowances , and limitations of the member’s benefit plan.


For more information, please review Section 3: The Role of the Provider and Magellan in the Provider Handbook Supplement for Virginia Behavioral Health Service Administrator (BHSA)

MCOs and Service Coordination

Per DMAS, Managed Care Organizations [MCOs] coordinate care for Medicaid populations with special needs. Coordinated care is an approach to delivering and financing health care aimed at improving the quality of care while also saving costs.

The fundamental idea is twofold:

(1) to improve access to care and coordination of care by assuring enrollees have a medical home with a primary care provider

and

(2) to rely more heavily on preventive and primary care.

Mental health services for Medicaid members may be covered by the BHSA or by the member’s MCO. Non-traditional mental health services are covered through the BHSA.

Care Coordination May 2016 13

MCOs and Service Coordination [cont]

The MCOs and Magellan work together to provide a more consistent referral system for members who live with mental illness and physical illness. Promoting communication between all mental health providers and medical health providers will improve overall health outcomes for members.

Care coordination models are one of the premier opportunities for participating plans to demonstrate innovative approaches and show the power of program integration. DMAS should continue to focus on specifying the outcomes desired rather than on the details of the process of care, which should be individualized to the particular needs.

Care coordination can be improved by engaging providers and holding them accountable for results.

May 2016 14 Care Coordination

Examples of Magellan and MCO coordination

Examples when Magellan may provide service coordination with the MCOs to assist individuals and families include:

Members transitioning between a hospital stay and community mental health treatment may need their MCO and the BHSA to communicate about services available to support the member at discharge.

Members transitioning from a state facility back to the community may need the BHSA to coordinate with their MCO once they are reinstated to assure transition to traditional out patient services and outpatient psychiatric services.

Ambulatory follow-up and discharge planning (including follow-up appointments) for all individuals in inpatient and/or residential settings under their management.


Examples of Magellan and MCO coordination [cont.]

Members who move from MCO to MCO or from Commonwealth Care Coordination or the Behavioral Health Home Pilot Project to traditional Medicaid Fee For Services also often need assistance in coordinating services.

An MCO liaison at the BHSA will work with MCOs to develop strategies for identification of individuals with co-morbid behavioral health and medical needs and facilitate referrals into respective systems of care.

Care coordination with Primary Care Physicians (PCPs).


Coordination of care with a Primary Care Physician [PCP]

On CMHR Initial Review and Continued Stay Review Service Request Authorization [SRA] forms the following questions are asked:

•Does the individual have a primary care physician (PCP)?

•If yes, has there been communication with the PCP to provider updates regarding treatment and service coordination?

•If yes, name of Physician:

•If not, have there been efforts to connect the individual with a PCP?


Magellan TRR Care Coordination audit tool questions

On the Magellan Treatment Record Review [TRR] tool, an entire section is focused on coordination of care and sharing of information between a provider and a member’s Primary Care Physician [PCP] and/or other behavioral health providers.

SECTION H: Coordination of Care

1H. Evidence of provider request of consumer for authorization for PCP communication

2H. Evidence consumer refused authorization for PCP communication

3H. PCP communication after initial assessment/evaluation

4H. Evidence of PCP communication at other significant points in treatment, e.g.: - Medication initiated, discontinued, or significantly altered - Significant changes in diagnosis or clinical status - At termination of treatment

5H. Treatment Record reflects continuity and coordination of care between primary behavioral health clinician and (note all that apply under comments): - psychiatrist - treatment programs/institutions - other behavioral health providers - ancillary providers


Conclusion

Care Coordination is completed by service providers ; a collaboration and sharing of information among health care providers, who are involved with a member’s health care, to improve care.

Service Coordination is provided through the MCOs and BHSA in the spirit of collaboration with the treatment team and is meant to support the member on his or

her path of recovery.

Care Management is provided by Magellan to help members receive quality services in the most cost-effective manner through optimizing their benefits by reviewing and authorizing appropriate services to meet their behavioral healthcare needs in a timely manner.

In conclusion, Magellan wants to ensure that members receive all needed services and support, and these resources are well-coordinated and integrated, and they are provided in the most effective and efficient manner possible.


Questions?

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Disclaimer

This presentation is based on care coordination information. It is not based solely on Virginia Department of Medical Assistance Services Regulations or the Virginia Department of Behavioral Health and Developmental Services Regulations. The information in this presentation does compliment the regulations of both departments.


Confidentiality Statement for Educational Presentations

By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.


For questions about the Medicaid behavioral health benefits managed by Magellan of Virginia or the information covered in

this presentation, please contact the Magellan of Virginia at

(800) 424-4046.

Thank you!

23 May 2016 Care Coordination

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