STAR+PLUS Nursing Facility - Member Service Coordination MHTNF_SCTraining_101316

Transcription

1 STAR+PLUS Nursing Facility - Member Service Coordination MHTNF_SCTraining_

2 Our Story and Who We Are Our story is about being a family The Molina Healthcare story is about one man s belief that when it comes to health care everyone should be treated like family. It was in 1980 when as an emergency room physician, C. David Molina, MD, noticed that low-income, uninsured or non-english speaking patients were coming to the emergency room in need of general health care services. Without family doctors, they were not always getting the right care and information. These underserved families deserved better and Dr. Molina set out to do something about it. He opened a clinic in Long Beach, California to provide lowincome individuals and families with a place to go to get personalized health care from Molina doctors. Two more clinics opened that same year and today our health plans and clinics serve patients across the country. What started out as a mission to treat patients like family has today become a family mission Never forgetting their roots, Molina children once put in charge of sweeping the floors, stocking shelves and filing medical records now lead the company s operations and strategic direction 2

3 Vision, Mission and Values Our Vision: We envision a future where everyone receives quality health care. Our Mission: To provide quality health care to persons receiving government assistance. We strive to be an exemplary organization Our Values: Caring: We care about those we serve and advocate on their behalf. We assume the best about people and listen so that we can learn. Enthusiastic: We enthusiastically address problems and seek creative solutions. Respectful: We respect each other and value ethical business practices. Focused: We focus on our mission. Thrifty: We are careful with scarce resources. Little things matter and the nickels add up. Accountable: We are personally accountable for our actions and collaborate to get results. Feedback: We strive to improve the organization and achieve meaningful change through feedback and coaching. Feedback is a gift. One Molina: We are one organization. We are a team. 3

4 Purpose of STAR+PLUS Nursing Facility (NF) Program The goal of the STAR+PLUS program is to integrate acute and long term care services into a managed care delivery system. Populations included: Medicaid recipients, age 21 and older, getting Supplemental Security Income (SSI) benefits Medicaid recipients, age 21 and older, not getting Supplemental Security Income (SSI) benefits People who get Medicaid through Social Security Exclusion Programs People with both Medicaid and Medicare ( aka dual - eligibles ) Elderly or disabled individuals, including children, who require long-term care, including short-term nursing facility care Providing nursing facility services through STAR+PLUS is expected to: Improve quality of care for nursing facility residents through coordination of health and service care needs Promote care in the least restrictive, most appropriate setting Include service coordination for nursing facility residents 4

5 Healthcare Services Structure Service Coordination (SC) Long-Term Services and Support (LTSS) Case Managers Case Managers responsible for Molina members admitted from the community to a NF for a short term stay If the member s long term goal is to remain in the nursing facility for custodial placement, the LTSS Case Manager will transition the member to a NF Case Manager for member management Nursing Facility Case Managers (also know as Service Coordinators) RN Case Managers for Molina NF custodial members Case load is determined by membership needs and geographic location Utilization Management (UM) Case Managers responsible for reviewing Prior Authorization (PA) to determine medical necessity If medical necessity cannot be determined by the UM nurse, PA to be routed to the Medical Director for review Medical Affairs Medical Directors conduct Molina Internal Interdisciplinary Care Team (ICT) Rounds Conduct Peer-to-Peer reviews for members needing additional PA review 5

6 Service Coordination in Nursing Facilities Service Coordinators (SC) will partner with NF care coordinators and other NF staff to ensure members care is holistically integrated and coordinated. The goals of Service Coordination include emphasis on: Preventive care Improved access to care Appropriate utilization of services Improved member and provider satisfaction Improved health outcomes, quality of care and cost effectiveness Promotion of care in the least restrictive and most appropriate setting Finding ways to avoid preventable hospital admissions, readmissions, and emergency room visits 6

7 Responsibilities of Molina Service Coordinators Partner with the member, family, and NF staff in the development of a Molina Service Plan Service Plan to include: Services provided through the NF, add-on services, acute medical services, behavioral health services, and primary or specialty care. The approval of additional services outside of the NF daily unit rate is based on medical necessity and benefit structure. The Service Plan is Molina s document that demonstrates the type of care and services the member is receiving from various healthcare providers. The Molina Service Plan is an internal document and is not part of the member s NF clinical record. Comprehensively review the member's Service Plan and NF plan of care, at least annually and as needed with notification of a significant change of condition. Support care planning by participating in NF care planning meetings telephonically or in person, provided the member does not object. Work with the resident, families, and other service coordinators to ensure smooth transition into the nursing facility. 7

8 Responsibilities of Molina Service Coordinator Visit with member on a quarterly basis. Visits to include: A review of the member's Nursing Facility care plan, a person-centered discussion with the member or responsible party about the services and supports the member is receiving, any unmet needs or gaps in the member's care plan, and other aspect of the member's life or situation that may need to be addressed. Assisting with the collection of applied income when a NF has documented unsuccessful efforts, per the state-mandated NF requirements. Notify the NF within five days of a change to the Molina assigned service coordinator. Return a call from the NF within 24 hours. 8

9 Responsibilities of Molina Service Coordinators Cooperate with representatives of regulatory and investigating entities including DADS Regulatory Services, the LTC Ombudsman Program, DADS trust fund monitors, Adult Protective Services, the Office of the Inspector General, and law enforcement. Fulfilling the requirements of the Texas Promoting Independence Initiative (PII) as described in UMCC The Service Coordinator can be the point of contact for an individual referred to return to the community under PII --- better known as the Money Follows the Person program. Coordinate with the NF discharge planning staff to plan the member s discharge and transition from the NF. The NF is ultimately responsible for a safe discharge. 9

10 Nursing Facility Collaboration With Service Coordination Invite the Molina Service Coordinator to provide input for the development of the NF care plan, subject to the member's right to refuse, by notifying the MCO Service Coordinator when the interdisciplinary team is scheduled to meet. NF care planning meetings should not be contingent on the Molina Service Coordinator s participation. Provide the Service Coordinator with the NF Care Plan Schedule. Coordinate with the Molina Service Coordinator to plan the member s discharge and transition from a NF. The NF is ultimately responsible to assure a safe discharge. Provide the Molina Service Coordinator access to the facility, NF staff, and member s medical information and records. Provide Service Coordinator access and training to any electronic medical record system. 10

11 Nursing Facility Notifications to Service Coordination The NF should notify Molina Service Coordination within one business day of the following events: Unplanned admission or discharge to a hospital or other acute facility, skilled bed, or another nursing home; long term care services and supports (community/home). Adverse change in a member's physical or mental condition or environment that could potentially lead to hospitalization. Emergency room visit. Other Notifications: Notify the MCO Service Coordinator of any allegations of abuse or neglect or reportable incidents to DADS that involves a Molina member. Provide the Service Coordinator with a copy of the DADS Investigative Report (form 3616A) and supporting documentation for any incident reported to DADS that involves a Molina member. Notifying the MCO Service Coordinator of any other important circumstances such as the relocation of residents due to a natural disaster. Notifying the MCO Service Coordinator if a member moves into hospice care. Notifying the MCO Service Coordinator within 72 hours of a member's death. 11

12 Nursing Facility Notifications to Service Coordination Molina Service Coordination Phone Line: Molina Service Coordination FAX Line: Notifications can be verbal or via fax Notification can directly ed to the assigned Service Coordinator The Standard Service Coordination form is accepted The electronic notification through SimpleLTC is accepted Reminder: All transmission of protected health information must be submitted in a secure format to assure privacy for the member. 12

13 Service Coordination Visits Molina service coordinators will conduct a comprehensive review of a member s service plan via quarterly face-to-face assessments, or more frequently as determined by the member s needs. The Service Coordinator serves as an advocate for the member Reviews the care provided by the NF provider Identifies gaps in care or possible gaps in documentation of care Works collaboratively with the NF to assure the needs of the member are identified and addressed Type of Visits: New Nursing Facility Visit Conducted for newly contracted facilities or with a change of Administrator/DON and/or with a change in Molina Service Coordinator Visit intended to: Define roles and expectations between the NF and Service Coordinator Identify NF point person Exchange contact information Establish access to clinical records 13

14 Service Coordination Visits Re-Assessment Visits/Significant Change of Condition Visits Conducted quarterly could be more frequently based on member needs Visit to include: Service Coordinator will check in with NF designated point person to discuss NF and member specific needs/changes. Interview member/responsible party to evaluate the member's Molina Service Plan, identify and support unmet needs or gaps, desire to return to the community and any other aspect of the member's life or situation that may need to be addressed. Review NF records i.e.: MDS, H&P, Labs, Physician Orders, etc. Service Coordinator will collaborate with the NF to help identify gaps in care or documentation, and other opportunities for improvement in the documentation, care and services provided by the NF. Service Coordinator's participation in NF care plan meetings, as allowed by member. Understand current services in anticipation of future care needs. Assist the NF with member preventative care needs/services and identify resources/providers. Exit/debrief with designated NF contact. 14

15 Service Coordination and Prior Authorization of Services The Service Coordinator may identify and support, along with the NF, the need for additional services such as: Skilled Care In-Place (MMP members only) Add-On Therapy (STAR+PLUS only, formerly GDT) PT, OT, ST (also known as Part B Therapy for Medicare and MMP members) Additional services that require prior authorization must be submitted through Utilization Management for review of medical necessity. The Service Coordinator cannot issue prior authorization, but will assist the NF in requesting prior authorization and/or check status of a prior authorization request. For more information on Prior Authorization Requirements: 15

16 Service Coordination Best Practices The NF should schedule Molina member care plan meetings on the same day and in time blocks. Example: Molina Member Care Plan meetings held on Thursdays from 10:00 am 12:00 pm The NF to notify Service Coordinator of new admissions, discharges, and changes of condition, daily after the morning meeting. Bring a stack of Service Coordination Notification forms to the morning meeting and complete them as you learn the information, then fax after the meeting. The NF to involve the Service Coordinator early in any member or family care concern issues. The Service Coordinator can be a mediator, helping to bring parties together to focus on what is best for the member. The NF to utilize the Service Coordinator as a resource The Service Coordinator can navigate the Molina systems to identify resources available to the member. Example: Securing appointments with specialist or accessing the Molina Value Added Services. 16

17 Service Coordination Best Practices Discharge Planning The Service Coordinator can assist and support the NF in the discharge planning process. Start discharge planning early the better the plan, the greater success for member. The Service Coordinator can assist in identifying what is the appropriate level of care for discharge. The Service Coordinator can identify what resources and services are available to the member. Preventive Care The Service Coordinator can collaborate with the NF on preventive care programs impacting the overall health of the member. The Service Coordinator can provide the member with education on their health status or specific health concern. Quality Assurance and Performance Improvement (QAIP) The Service Coordinator can support any quality improvement plans. Example: Reduction of Antipsychotic Usage the Service Coordinator can assist in reviewing the member s medication, make recommendations for other approaches, identify other Molina resources that my be available to the member, provide education the member and/or family/responsible Party of the appropriate use of antipsychotic meds. 17

18 Money Follows the Person (MFP) The Money Follows the Person program is one of several ways Texas has responded to the 1999 U.S. Supreme Court decision in Olmstead v. L.C. (119 S. Ct (1999)). In that case, the Court decided that states cannot discriminate against people with disabilities by offering them long-term care services only in institutions when they could be served in the community, if state resources and other citizens' long-term care needs permit it. As a result of the decision, many states, including Texas, have begun various efforts to reduce the number of people in institutions and increase the number in home- and community-based programs, often as part of an overall effort to rebalance the long-term care system. Under Texas' Money Follows the Person program, people can move from nursing homes to the community without having to spend time on a waiting list for community-based services like people still living in the community who need these services (the waiting lists are considerable in Texas). It also permits public money, up to the amount that was spent on them in the nursing home, to follow them to the community (although in reality the cost of community care is usually considerably less than in the nursing home). 18

19 Money Follows the Person (MFP) To access Money Follows the Person a member must: Live in a Medicaid nursing home (Long Term Care Bed) Be eligible for Medicaid community services Be approved for waiver services What the Money Follow the Person (MFP) program can do for nursing facility residents: Locate and secure affordable housing Assist with security deposit Provide household items Provide assistive equipment and devices *(when needed) Arrange for minor home modifications to ensure independent safe functioning Provide training in independent living skills Make referrals of personal assistant services Provide personal assistant management training Provide case management 19

20 Money Follows the Person (MFP) Transition Assistance Services (TAS) One-time grants of up to $2,500 in TAS funds are available to nursing facility residents who are moving from the facility to certain types of living arrangements. They are designed to be used to purchase certain items necessary to set up a household, including: Essential furnishings Moving expenses Rental security deposits Services to ensure health and safety Utility service deposits Transition to Life in the Community (TLC) grants These grants provide a one-time assistance of up to $2,500 to help nursing facility residents move to community settings; however, TAS funds must be used before TLC funds. 20

21 Money Follows the Person (MFP) Housing Voucher Program The Project Access Voucher (PAV) provides rental assistance for people relocating from a Nursing Facility setting. The Texas Department of Housing and Community Affairs are working in partnership to distribute the vouchers. Community Transition Teams Community Transition Teams are public-private regional community resources coordinating groups who work with individuals and systemic barriers to community relocation. One team in each of the DADS regions meets monthly to address specific barriers that prevent a Nursing Facility resident from relocating into the community. 21

22 Money Follows the Person (MFP) Referrals for the MFP Program may come from the Nursing Facility Resident, Social Worker, Power of Attorney or Resident s Family. For more information: The assigned Molina Service Coordinator is also a point of contact Molina has designated Case Managers to work specifically with the MFP program A series of assessments must be completed on the member to determine if they qualify for MFP. Home assessments must be completed as well to determine if there is a safe environment for the member. MFP cases are a slow, meticulous process to assure the member s need will be met and can be sustained in the community. The Nursing Facility Social Worker is a key role in MFP from the perspective of assuring a safe discharge for the member. 22

23 Service Coordination Success Stories Member CM in El Paso: The member was needing ophthalmology care as well as dental care. The Service Coordinator worked with the NF to obtain appointments with network providers. The Service Coordinator assisted the member in accessing their Value Added Services benefit of $250 for routine dental services. The Impact: The member received an ophthalmology exam and new eyeglasses, thus improving quality of life through better vision The member had a dental exam and cleaning which the relieved the member s anxiety about their dental status as well as provided the preventive care impacting overall health status. 23

24 Service Coordination Success Stories Member MH in Dallas: The member had several complaints about the NF and was frustrated with the care being received, specifically the lack of physician intervention to address his multiple health issues. The member wanted to move to Austin and had additionally complained to the State about his care. The Service Coordinator met with the NF team and the member to discuss the concerns. The Service Coordinator worked with the NF Social Worker to obtain appointments with a dermatologist, a surgeon, a Hepatic specialist and a pain specialist. The Service Coordinator provided education to the member as well about managing his chronic health conditions. The Service Coordinator continues to follow up with the member at the NF to assure he is managing his conditions, and the NF is providing appropriate care to meet his needs. The Impact: The member has seen specialist as needed preventing possible ER visits and further complications. Having routine specialist physician care can prevent future hospitalizations. The member s quality of life has improved by feeling better and getting proper care. The member no longer wants to move to Austin, and wants to stay at his NF as he feels they are taking good care of him now! 24

25 Molina Healthcare of Texas Service Coordination Resources STAR+PLUS Nursing Facility Member Handbook US/PDF/Medicaid/STAR+PLUS/star-plus-memberhandbook-2015.pdf Molina Healthcare Nursing Facility Provider Manual id/manual/pdf/provider-manual-nursing-facility.pdf Molina Prior Authorization Guide id/forms/pdf/pa-pre-service-review-guide.pdf 25