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The care coaching model of case management provided through the Medicare-Medicaid Alignment Initiative (MAI) in Illinois provides social support to people at risk for escalating health problems.
Care coaches provide follow-up and care coordination for a Medicaid population of elderly and disabled members. "We are subcontractors of a health plan," says Kathleen Miodonski, RN, BSN, CMAC, vice president of clinical operations at Post Acute Network Solutions in Rosemont, IL.
"We introduce ourselves and the health plan benefits to residents on this list," Miodonski says. "We explain what the program is about and what the health plan offers to them, and then we do a health risk assessment."
Care coaches, who have nursing degrees including BSNs and master’s degrees, identify a member’s chief obstacles to staying healthy and out of the hospital, and implement a plan. Their chief attributes include organizational skills since they are completely independent as they work in the field. They also must work well under tight time demands and manage the documentation and review of care plans while balancing the needs of up to 75 people, Miodonski says.
Here are some of the services they provide:
Refer patients to ancillary services. Care coaches might see a patient with hearing loss and help her obtain a hearing evaluation and then get a hearing aid. Or they might visit with a patient whose chronic pain is due to poor oral hygiene, and they’ll refer the person to dental benefits, Miodonski says.
Provide transportation set-up. If a plan member’s family is unable to drive him or her to doctor’s visits, then the care coach will find a transportation solution, says Karen Bonner, CCM, RN, MBA, field manager for Post Acute Network Solutions.
Coordinate care. "One of our jobs is to work with a facility and the member’s family and have those difficult conversations," Bonner says. "Maybe we need to look at something different, helping the family with advance directives and talking about end-of-life care."
Find simple solutions to obstacles. Bonner helped a man whose visual impairment made it unsafe for him to walk around alone. He was unhappily homebound. "He was having all kinds of falls and couldn’t go out into the community because it wasn’t safe," she says. "I got him a white cane to click from side to side to know the pathway is clear."
Bonner obtained a donation of the cane from a foundation, and she arranged for the man to receive training in using it. Now the man can walk outside and attend church services, which is very important to him, she adds.
Prevent polypharmacy problems. Members often have 12 or more medications, and often there are prescriptions that are not necessary, Miodonski says.
"We identify how many of these medications are necessary and whether a member is receiving any benefit from them," she says. "In some cases we have found there might be three different hypertensive drugs ordered."
The care coach might recommend a medication review and talk with family members about the member’s healthcare and medication concerns. "Part of the process is to look at which diagnoses are identified for the member and to see what kind of clinical conditions there are," Miodonski says. "Then we compare that to the medication list."
Sometimes care coaches will investigate to find out why a particular person has two hypertensive medications. It could be appropriate, or it could be the result of the member seeing different doctors who were each unaware of the other one, she adds.
Analyze frequent emergency department admissions. "Why are they going to the emergency department?" Miodonski says.
"We found that one of our members was going to the ER frequently with urinary tract infections," she explains. "We worked with physicians to address this aggressively to decrease her ED visits and hospitalizations."
Assist with dietary needs. Care coaches sometimes meet with members for lunch to see whether they are sticking to their doctor-recommended diet or to learn of any obstacles to healthier eating habits, Miodonski says.
Sometimes members with diabetes or hypertension need some assistance in determining which foods will help them remain stable.
Create tools to assist. Creativity is a hallmark of case management. One care coach had a member who was visually impaired and also had difficulty hearing. "What this member needed were markers and paper to write words in big enough letters that she could read them," Miodonski says. "The care coach helped her with that."
Those kinds of small tasks might seem trivial, but they can make a big difference in a MAI member’s life, she adds.
"These things are vitally important for people to feel connected, to communicate, and still feel alive," she says.