Cross System Care Coordination

Care Coordination

Importance of the role of care coordination and partnering across systems:

Medicare Advantage (MA) and Managed Care (MCO) plans are responsible to coordinate across systems of care just like Long Term Care (LTC) to help ensure timely and coordinated transitions of care (from institutions to community) and meet the needs of clients in the community.

How does care coordination benefit our mutual clients?

  • Increase our understanding of managed care services and supports
  • Increase Managed Care and Medicare Advantage plans understanding of the LTSS system and how to support shared clients
  • Offer new thinking around ways to improve coordination and collaboration as community transition planning partners and ongoing care coordination partners.​

When and How to Engage System Partners  

How to reach out to coordinate with our cross systems partners. 

Resources and Trainings

Trainings

Resources

Stakeholder Resources

Understanding each entities’ roles

Individuals responsible for achieving successful transitions of care and care or case management should be well versed on the services available to clients/beneficiaries and how to access them. While we cannot all be experts in all the things, we can partner across the delivery systems to address gaps in care and achieve more efficient and cost-effective service delivery.

Area Agency on Aging (AAA):

  • Information and Assistance (no wrong door access to local community services and supports)
  • Case management of Medicaid LTC clients served in their home.
  •  Conduct ongoing functional assessments for LTC and service plans
  • Assist with transition to LTC services or settings
  • Case management for other programs like supportive housing, state funded family caregiver support programs, Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA)
  • Some AAAs have special programs like Health Homes or care transitions
  • Contract Medicaid LTC providers
  •  Other social support services (local expertise) e.g.:
    •  Transportation
    • Nutrition Services – congregate or home delivered meals
    • Family Care Giver Support
    • Information and Assistance
    • Environmental modifications

Home and Community Services (HCS)

  • Initial eligibility determination for referrals to the Medicaid LTC system.
  • Financial eligibility determination for some Medicaid clients
  • Conduct person centered initial and ongoing functional assessment and service plan
  • Residential and SNF case management
  • Assist with referrals as identified in the functional assessment
  • Assist with transitions of care from inpatient to community LTC and from different LTC settings.
  • Authorize Medicaid LTC services
  • Contract LTC residential settings and services

Dual Special Needs Plan (D SNP) Medicare and Managed Care Organization (MCOs) Medicaid:

  • Responsible to cover Medicare and Medicaid services
  • Responsible to conduct an Initial Health Risk Assessment and offer care management services if indicated.
  • Assist with transition planning and responsible to locate and assist with scheduling post discharge appointments with providers
  • Coordination with the BHSO (behavioral health plan) and LTSS as appropriate
  • Reviews/approves authorization requests for Durable Medical Equipment (DME)
  • Timely Prior Authorizations for medically necessary care like SNF, Home Health or other care
  • Track in-patient stays and identify opportunities for early intervention, assist with transitions
  • Responsibility for Medicare and Medicaid covered benefits and to coordinate Medicare and Medicaid benefits and services
  • Offer Supplemental Benefits (vary depending on the plan) could include:
    • Transportation
    •  PERS
    • Transitional Meals
    • Utilities, Over the Counter (vitamins, basic supplies), and Healthy Food Card