CareSource The Managed Care

Difference

Mission: The CareSource HeartbeatMaking a difference in the lives of underserved

people by improving their health care

Vision CareSource will be an innovative leader in the management of quality public sector health

care programs

CareSource Model Non-profit, mission driven Member Focused

• Enhanced benefits, no co-pays• CareSource 24 nurse triage service – excellent

customer satisfaction• Care Management continuum – member

centric care• Community based care management,

marketing, and provider relations programs• Regional Consumer Councils

Provider Focused• Physician enhanced reimbursement• Low hassle approach to medical management• Health Care Home Program• Provider portal tools to promote preventative

and wellness activities Best practice administrative efficiencies Technology investments

Why Managed Care? Quality• NCQA, URAC and best practice

compliant Accountability to Policymakers and

Taxpayers Budget Predictability Improved Access to Quality Health Care• Credentialing and provider

collaboratives Focus on Coordination of Care Cost Savings

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What Can Managed Care Do?

Challenges lead to opportunities in managing Medicaid members

• Addressing socioeconomic limitations

• Initiatives to improve access to quality, cost effective healthcare

• Management of multiple chronic and co-morbid disease states

• Integrated behavioral/physical health4

CareSource Focus

Quality provider network Integrated Care-• Mental Health, Substance Use

Disorders and Physical Health Medical Home-• Behavioral Health

Case Management Partnerships-• Access• Services-Evidenced Based Practices

Integrated Care

Mental Health, Substance Use Disorders and Physical Health• Improved Outcomes • Increased Efficiency• Increased Effectiveness• Increased Flexibility• Decreased Costs• Decreased Administrative Burden

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Medical Home

Behavioral Health• Patient Centered• Facilitates partnerships between

individual patients, personal physicians and patient’s family

• Bi-directional

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Behavioral Health Core Services

Evidenced Based Practices (EBPs)• ACT• Medication Management• Family Psychoeducation• Integrated Mental Health and

Substance Use Services• Illness Self Management

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Evidenced Based Practices Gaps in access to these services due to

the complexity and fragmentation of the current healthcare system • Administered by different systems

with different rules• Subject to different funding streams

Explore expanding relationships to allow for coverage of these critical services

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CareSource Care Management

Case and Disease Management Clinical Care Advance Care Management Support Services Special Needs Plan

• Medicare Quality Improvement Medical Management/Utilization Management Triage/Clinical Call Center Behavioral Health/Controlled Substance Member

Management Business Analysts

Behavioral Health Services

Traditional Case Management Intensive Case ManagementCARE4U Case ManagemetBridge to Home

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Behavioral Health Team The BH Team consists of Case and Medical

Management for members with BH needs BH Medical Management team is comprised of:

• Patient Care Coordinators (PCC) - RNs and SW• Prior Auth Specialists (PAS) - non clinical

administrative support• Psychiatric Consultants

Case Management team is comprised of: • RN’s, SW and Psychiatric Consultants • Case Management includes care for Low,

medium and high stratification members and a BH Intense Case Management Program

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Reliance on Partnerships

State and County Government Agencies

Service Providers

Advocacy organizations