Sunshine Health Managed Medical Assistance (MMA) Program

Transcription

1 Sunshine Health Managed Medical Assistance (MMA) Program 1

2 Three Key Products Sunshine Health Managed Medical Assistance (MMA) Sunshine Health Child Welfare Sunshine Health Tango Plan Long-Term Care (LTC) 2

3 Regions by Counties/MMA 3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union 4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia, 5 Pasco, and Pinellas 6 Hardee, Highlands, Hillsborough, Manatee, and Polk 7 Brevard, Orange, Osceola, and Seminole 8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota 9 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie 10 Broward 11 Miami-Dade and Monroe 3

4 Enrollment Process AHCA or its agents notifies Sunshine Health of an enrollee s selection or assignment to the Plan. AHCA or its enrollment broker sends written confirmation to enrollees of the chosen or assigned Managed Care Plan. Notice to the enrollee is sent by mail. Notice to Sunshine Health will be by file transfer. Sunshine Health will assign PCP to the enrollees who have not chosen a PCP. AHCA s confirmation notice will advise the enrollee of this process. Enrollment in Sunshine Health, whether chosen or assigned, will be effective at 12:01 a.m. on the first calendar day of the month following a selection or assignment that occurs between the first calendar day of the month and the last Saturday of the month. 4

5 New Member Information Upon enrollment in Sunshine Health, members receive a Member Handbook and a Sunshine Health Member ID card. NurseWise attempts to contact new members to complete a Health Risk Screening (HRS) to identify members with continuity of care needs or those who may benefit from case management. 5

6 Clinical Management 6

7 Top 10 Diagnoses 5.2 % Respiratory including: Bronchitis, COPD, Asthma, pneumonia, reactive airway 3.0 % Diabetes 2.8% Hypertension 2.5% Coronary Artery Disease including: Chest pain, MI, coronary artery blockage, HF Others: fractures, abdominal pain, infection/sepsis, gastroenteritis/colitis, kidney failure, behavioral health 7

8 Utilization Management Tools Some of the Utilization Management Tools: Policies and Procedures InterQual Concurrent review for inpatient admissions Daily reports such as census, turn around time, admits/day 1000 Medical Management System- TruCare Fax system- Right fax and FileNet (CDMS) Claims system- Amisys Customer Relationship Management (CRM) Provider Data Management (PDM) 8

9 Case Management Centene and Sunshine Health adhere to the Case Management Society of America s (CMSA) definition of case management. A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual s health needs through communication and available resources to promote quality cost-effective outcomes. Case management is appropriate for members needing a higher level of service with clinical needs. Members in case management may have a complex condition, multiple co-morbidities or those that are frail, elderly, disabled, or at the end of life. Members in case management typically can benefit from education on how to manage their health condition(s), assistance in accessing health care services, linking to community resources, and additional family or other care giver support/education. These members mostly need moderate to minimal assistance from a case manager for a short period of time. 9

10 Health Management Programs Health management programs are managed by our partner Nurtur. Interventions and educational programs designed for individuals with chronic conditions designed to prevent recurrence of symptoms, maintain high quality of life, and prevent future need for medical resources by using an integrated, comprehensive approach to healthcare. Nurtur provides the following programs: Diabetes Mellitus (DM) Heart Failure Chronic Obstructive Pulmonary Disease (COPD) Asthma Hypertension (HTN) Developmental Delay and Autism 10

11 Health and Wellness Designed to address the health status of our members across the continuum of health from wellness to the management of one or more chronic conditions. It is rooted in the philosophy of meeting the member where they are, supporting them to take that first step, and to continue the healthy behaviors necessary to improve their health. Health and Wellness Condition Management Lifestyle Risk Behaviors 11

12 Behavioral Health 12

13 Appointment Standards Type of Care Emergency Care with Crisis Stabilization Urgent Care Post Discharge from Hospital Routine Referrals Standard Within twenty-four (24) hours. Within forty-eight (48) hours. Within seven (7) days. Fourteen (14) calendar days. 13

14 Provider Resources Provider Manual Quick Reference Guide Frequently Asked Questions Provider Directory Cultural Competency Plan Outpatient Treatment Request (OTR) Form PCP Communication Form Address Change/Update Form E-Learning User Manual Provider Portal Educational Brochures 14

15 Covered Services Inpatient Mental Health. Observation. Electroconvulsive Therapy (ECT). Outpatient Mental Health services provided by a psychiatrist including medication management. Community Mental Health Center Services. Crisis Services. Adult and Child Targeted Case Management. Federally Qualified Health Center (FQHC), Rural Health Center (RHC), and Primary Care Clinic (PCC) Behavioral Health Services. 15

16 Covered Services (continued) Substance use services for children, pregnant women, and in cases where acute care physical health services related to substance use or detoxification are necessary. Residential Treatment for Mental Health and Substance Abuse. Statewide Inpatient Psychiatric Programs (SIPP) Art Therapy. Telemedicine. 16

17 Standards of Care Sunshine Health focuses on collaborating with providers to ensure the best care and outcomes possible, and coordination with our ICM/CC staff is imperative. As an NCQA accredited organization, Sunshine Health adheres to HEDIS seven day follow up measures when a member has been discharged from an inpatient setting. Our expectation is that a member will have a follow up appointment scheduled with a licensed behavioral health professional within seven days at the time of discharge. Sunshine Health case management staff are able to assist as needed with scheduling this appointment. 17

18 Standards of Care (continued) Additionally, Sunshine Health case management staff will follow up with members after discharge to assist with alleviating any barriers to treatment adherence with this appointment. Case management Staff also provide members with discharge tool kits to provide resources related to mental illness, medication adherence, developing a wellness plan etc. 18

19 Case Management We recognize that multiple co-morbidities will be common among our membership. The goal of our program is to collaborate with the member and all treating providers to achieve the highest possible levels of wellness, functioning and quality of life. Sunshine Health s case management model uses an integrated team of: Licensed mental health professionals Registered nurses Social workers Non-clinical staff 19

20 Case Management (continued) Sunshine Health s case management model is designed to: Educate members on the importance of treatment compliance. Help members obtain needed services. Assist in coordination of covered services, community services, or other non-covered venues. 20

21 Why We Integrate Care People with mental and/or substance abuse disorders may die decades earlier than the average person. Mostly from untreated and preventable chronic illnesses like: hypertension diabetes obesity cardiovascular disease These illnesses are aggravated by poor health habits like: inadequate physical activity poor nutrition smoking substance abuse Barriers to primary care coupled with challenges in navigating complex healthcare systems have been a major obstacle to care. 21

22 Clinical Behavioral Health Models Integrated Care Clinical Training and Development Disease Management Child Welfare 22

23 Integration of Physical and Behavior Health Within thirty days the case manager completes an assessment to help determine the behavioral health and physical health needs. When a member has both behavioral health and physical health conditions, the case manager follows the process identified in the four quadrant integration model to assign a primary case manager. The model serves as the conceptual framework for collaborative planning. Each quadrant considers the behavioral health and physical health risks and complexity of the population and appropriate ways to meet the member s needs. ICM/CC will provide coordination of services for members.. ICM/CC will assure member has a 7 day f/u appt post DC. ICM/CC will provide calls to OP providers to confirm appointments are in place. ICM/CC will follow up with OP providers to confirm appointments have been attended. (if hospital has failed to schedule and/or coordinate efforts with ICM/CC, ICM/CC to schedule a 7 day f/u appt utilizing list of contracted providers 23

24 Different Levels of Intervention Based on an assessment of the member s physical and behavioral health conditions, social considerations, and other barriers, the level of intervention to support the member is determined. This can be: High follow-up at least weekly Moderate follow-up at least monthly Low follow-up at least quarterly From this determination, case management or care coordination occurs. Key Interventions Coordinate care with the member s PCP and behavioral health provider Facilitate communication across member s all treating providers and continuum of care Facilitate appointments for all needed care Educate member and caregivers about their diagnoses, self-management principles, identification of symptoms, and medications. Educate member on their benefits and how to access them Identify and facilitate linkage to appropriate community supports 24

25 Summary Sunshine Health uses a complex coordinated approach that involves input from: AHCA Providers Clinical Staff Pharmacy Staff Training Team Quality Staff Members 25

26 Contact Information: Medical Management Debra Smyers, SVP, Med Management, Medical Affairs (866) Behavioral Health Rebekah Paone, Clinical Director (866) Tonia James, Clinical Manager (866)