Subject: Coordination and Continuity of Care for enrollees with Special Healthcare Needs Services for DMAP Members (Page 1 of 5)

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1 (Page 1 of 5) Objective: To ensure that Health Share/ Tuality Health Alliance (THA) members with special needs are identified and provided individual attention directed to meeting their special health care needs. Definition of Coordination and Continuity of Care for Enrollees with Special Healthcare Needs Services: A specialized case management service that is provided by THA to Oregon Health Plan (OHP) members who are aged, blind, disabled, or have special health care needs as defined in the OAR guidelines. Coordination and Continuity of Care for Enrollees with Special Healthcare Needs services include: I. Early identification of those DMAP Members who are Aged, Blind, Disabled or who have complex medical needs. II. Assistance to ensure timely access to providers and services. III. IV. Coordination with providers to ensure consideration is given to unique needs in treatment planning. Assistance to providers with coordination of services and discharge planning. V. Aid with coordinating community support and social service systems linkage with medical care systems, as necessary and appropriate. Requirements Health Share/ Tuality Health Alliance (THA), under the Oregon Health Plan, provide the services of Coordination and Continuity of Care for Enrollees with Special Healthcare Needs through THA Nurse Case Management and a Coordination and Continuity of Care for Enrollees with Special Healthcare Needs Community Outreach Specialists (COS). A. Required skills of the THA Coordination and Continuity of Care for Enrollees with Special Healthcare Needs COS and Nurse Case Managers are advanced communication and

2 (Page 2 of 5) interpersonal skills that utilize consideration of body language, filters, listening, paraphrasing, and questioning with customers of diverse ethnic and cultural backgrounds and varied ages. B. This also includes the skills to obtain and interpret information that may be appropriate to patients' needs and age as required for assessment, range of treatment and patient care. C. THA has a mechanism in place for early identification of Aged, Blind, Disabled, or special health needs. This mechanism shows members of the Division of Medical Assistance Programs (DMAP) that have disabilities or complex medical needs. This mechanism pulls people identified by codes through the state, and captures them through a database. This information is then interpreted and investigated by the medical management team to determine if this person meets Coordination and Continuity of Care for Enrollees with Special Healthcare Needs criteria based on the special needs definition and by medical review of each member. D. The special needs definition is as follows: Special Health Care Needs means individuals who have high health care needs, multiple chronic conditions, mental illness or Substance Use Disorders and either 1) have functional disabilities, or 2) live with health or social conditions that place them at risk of developing functional disabilities (for example, serious chronic illnesses, or certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care.) E. Members are identified as being eligible for Coordination and Continuity of Care for Enrollees with Special Healthcare Needs services according to their eligibility category in the DMAP enrollment files and medical screening criteria. Members may also be identified for services through self-referral, high utilization, from their Primary Care Physician (PCP), agency caseworker, his/her representative or other health care or social service agencies. F. Assistance is provided to members who may require extra help in accessing services in a timely manner. Information about services available through the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs program is communicated to the eligible member according to the most appropriate communication method including accommodations for: Hearing impaired Speech disabled Visually impaired Alternative languages, translation and interpretation or other cultural differences.

3 (Page 3 of 5) THA makes available to Department of Human Services agency staff, OHP Members or their representatives the name and telephone number of the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs Community Outreach Specialist upon request. THA will check the database once per week for any newly identified individuals. These individuals are selected by the state and pulled by PERC codes. These individuals who show up on the database will then be reviewed by the nurse case managers and Community Outreach Specialists (COS). If it is determined these people have special needs the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs COS s and nurse case managers will follow up with the member. Referrals will be facilitated as appropriate. Coordination and Continuity of Care for Enrollees with Special Healthcare Needs interactions between members and case managers and/ or community outreach specialists will be documented within the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs spreadsheet. If it is determined that the member does not have special needs this will be documented in the case management log and member spreadsheet. Coordination and Continuity of Care for Enrollees with Special Healthcare Needs Services will be available during medical management team working hours. Procedures: A. Community Outreach Specialists will update Special Health Care Needs members by using the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs database on Tuesday of each week. Any member newly eligible of Coordination and Continuity of Care for Enrollees with Special Healthcare Needs services will be updated on a spreadsheet as a potential special needs recipient. B. The initially flagged Special Health Care Needs members will be documented in the Special Health Care Needs spreadsheet. It will contain their full name, date of birth, phone number, and address. It will also contain a tab for documenting follow-up with case management assignment and notes section. There will be identifiers for each Special Health Care Needs member that shows whether they qualified as exceptional needs or not, based on the special needs criteria. For tracking purposes this spreadsheet will also include previously established Special Health Care Needs people from January 1, 2015 forward. C. The Special Healthcare Needs identified members will undergo chart review the following day they are identified by a COS. This will come from one or all of the following sources: Cerner, referrals, chart notes from PCP offices, and/or claims data. If a Special Healthcare Needs member is identified this review will be sent on to the nurse case managers once a problem list has been identified. The RN case managers will ultimately decide if any of the established problems and/or medical conditions that were

4 (Page 4 of 5) found during the initial review are considered exceptional needs, and if they warrant special treatment and weekly management of the patient s needs. D. If the member s medical condition/s is determined to be regular and/ or a common medical problem(s) and they are being managed and cared for without any interventions in place, the member will then be crossed off the Special Health Care Needs identified members list. The RN case managers will document in the spreadsheet why this patient does not have exceptional needs based on their current medical conditions and environment. E. If this member is identified after the chart review as having special and exceptional needs, then the nurse case managers and COS will document this in the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs spreadsheet. The RN case manager will then add the explanation as to why they are special needs into the case management notes, located in the individual member file in the case management log. F. The nurse case managers will follow-up with the patient regarding any medical type of need. The COS s will follow-up with any social/environmental needs including; transportation, housing, food services, counseling services, and other services as appropriate and necessary. G. Once it has been documented that a particular member has special and/or exceptional needs, the nurse case managers and COS will meet bi-weekly to discuss this particular members needs. H. The nurse case managers and COS will meet bi-weekly to discuss the current and active members on the list. The discussions and resulting decisions that pertain to each member will be documented in the case management log. Bi-weekly meeting discussions will include current conditions of the patient, what referrals have been approved and received, what other services the patient may need at the current time and/or any other concerns that the RN case managers may have. I. If a member s condition resolves and improves to a point where exceptional care management is no longer needed this will be documented in the case management log as well as the spreadsheet. J. Any special referrals the team receives from outside medical or social services will need approval by nurse case managers prior to any of the services being rendered. K. Any referrals and special services given to member of Special Health Care Needs population will be documented under the members file in the Coordination and

5 (Page 5 of 5) Continuity of Care for Enrollees with Special Healthcare Needs spreadsheet and will be accessible for any reporting purposes to the medical management team. If the member falls off the plan and comes back on within 12 months a new review of the latest available health information will be done. Review of this compliance will be done by the QI team on a quarterly schedule. All quality checks to be performed through the Coordination and Continuity of Care for Enrollees with Special Healthcare Needs spreadsheet. Formulated: January 2015 THA Director