MEDICALLY COMPLEX CHILDREN S WAIVER

Transcription

1 MEDICALLY COMPLEX CHILDREN S WAIVER

2 About Us Who is South Carolina Solutions? We are a part of a Family of Companies. Our corporate office, Community Health Solutions, is located in St. Petersburg, FL. South Carolina Solutions has been providing care coordination services for the medically complex children s population since 2009 for the child and family in their natural environment. Over the years, SCS has become an industry leader in care coordination. We help children transition from the hospital to the community, offering a better quality of life for the children and their families while decreasing the cost of healthcare for the state. 2

3 What is the Medically Complex Children s Waiver? SC Department of Health and Human Services (DHHS) developed the Medically Complex Children s Waiver (MCCW) to assist families in the care of children with an acute or chronic illness/health condition that is expected to last longer than 12 months. DHHS initiated operation of the MCCW program in January 2009 expanding services to all 46 counties allowing state-wide access to the program. Since its inception, the program has served over 1500 patients throughout the state. The program is administered with a staff of Registered Nurse (RN) Care Coordinators located throughout the state to assist you in the care of the children in their community. We are your eyes and ears outside of the office. 3

4 Program Objectives RIGHT CARE, RIGHT TIME, RIGHT PLACE DHHS contracted South Carolina Solutions (SCS) to administer this program as an Enhanced Primary Care Case Management program which fits our company care model objectives: DELIVER a superior level of care that is effective, timely, efficient, family-centered, and safe for complex and chronically ill children DECREASE hospitalizations and emergency room visits resulting in a reduction in the mean cost of the beneficiaries MAXIMIZE the patient s health and function, leading to an improvement in quality of life through seamless highly integrated care coordination 4

5 Care Coordination The Care Coordinators provide you with a local RN who acts as a liaison between the waiver participant and all their providers for both medical and community based services. With the varied backgrounds of our pediatric nursing staff, we are able to serve as resources within our own program when a family encounters difficulty in providing care to their child. The care model is physician and medically driven and is overseen by the patient s Primary Care Physician (PCP). Examples of coordinated services include but are not limited to: Private duty nursing Medical daycare Personal care services Respite care DME Pharmaceuticals School Service Transportation 5

6 Why Should YOU Become A Participating Provider? 1. Benefits Free care coordination that produces a better outcome in the over all health of your patients In addition to your regular Fee For Service (FFS) billing, you will receive an additional $ per member per month (PMPM) provider enhancement bonus. 2. It requires very little change in your existing practices with these patients Participate in a team conference with the RN Care Coordinator every 6 months (this can be scheduled during a regular office visit) Monthly Contact with participant this can be done directly by the PCP office or by specialist with chart documentation. 6

7 Medically Complex Children s Waiver Conditions of Participation Contracted Physician Requirements What do you expect from me? Manage the medical and health care needs of members to assure that all medically necessary services are made available in a timely manner Monitor and follow-up on care provided by other medical service providers for diagnosis and treatment, to include services available under Medicaid fee-for-service Provide the coordination necessary for the referral of patients to specialists and for the referral of patients to services that may be available through Medicaid fee-for-service 7

8 Medically Complex Children s Waiver Conditions of Participation Maintain a medical record of all services rendered by the PCP and other referral providers. Monthly contact with members provided by one of the following: office visit specialty visit and report in client record direct telephone contact between the PCP and the responsible party documented in the client record Semi-annual team conferences involving the PCP, responsible party, client, and any other team members (as needed) to review the care plan. 8

9 Medically Complex Children s Waiver Eligibility Requirements Applicants Must Be: A resident of South Carolina Medicaid eligible May have primary commercial coverage and/or Medicare and Medicaid secondary SCS will assist with applying for TEFRA eligibility (Based on clinical diagnosis, not family income) Under the age of 18 Meet Medicaid Nursing Facility(NF) or Intermediate Care Facility- Mental Retardation(ICF-MR) level of care Meet medical criteria defined by the state *The state estimates there are about 12,000 patients eligible for the program. 9

10 Medically Complex Children s Waiver Medical Criteria The following are evaluated for medical eligibility: 1. Number of medications given routinely 2. Number of hospitalizations, emergency room visits, and sick visits to the PCP 3. Type of skilled care needs 4. Number of physicians involved 5. Number of therapies provided 10

11 1. Cerebral palsy 2. Seizure disorder Top 10 Most Common Diagnoses for the MCCW program (These are the most common, but eligibility is not limited to these diagnoses) 3. Congenital heart defects 4. Non-accidental trauma 5. Congenital anomalies 6. Chromosomal anomalies 7. Short gut syndrome 8. Developmental delays 9. Chronic respiratory issues 10. Pulmonary hypertension *Guideline - if they are SSI eligible, they should be screened for eligibility. **Approximately 30% of the clients require vent support of some type, i.e., C-Pap, Bi-Pap, or Ventilator dependence. 11

12 Medically Complex Children s Waiver Referrals Where do they come from? Hospital NICU and PICU Physician office Community Priority is given to Patients: Being discharged from the Hospital Requiring Private Duty Nursing Services In Foster Care Those not meeting the priority criteria are placed on a waiting list 12

13 Medically Complex Children s Waiver Referral Process A referral can be made to the MCC Waiver Program via: Online Portal: Phone: Fax:

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