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Software tool focuses on immediate needs
Program targets fee-for-service members
As part of a program targeting at-risk Medicaid fee-for service members, case managers at Hudson Health Plan are using a software tool that helps them focus in on the needs of their clients they should address first.
The Westchester Cares Action Program is being funded through a three-year grant program with the New York State Department of Health and targets 250 of the highest-risk, highest-need individuals enrolled in Medicaid fee-for-service in Westchester County.
The program involves Hudson case managers beta-testing the InterMed Complex Assessment Grid, a tool which was developed and used successfully in Europe, according to Margaret Leonard, MS, RN-BC, FNP, senior vice president for clinical services at Hudson Health Plan with headquarters in Tarrytown, NY. The Case Management Society of America (CMSA) has the rights to the tool in this country.
"CMSA has been working with the developers of the tool for quite some time. We are using this tool to prioritize and identify members who need care right away, enabling the case manager to hone in on and focus on what needs to be addressed immediately," she says.
The Department of Health uses an algorithm that identifies and stratifies the highest utilizing, highest cost Medicaid fee-for-service members and gives a list to the health plan. "Participants in the program face numerous psycho-social challenges in addition to their medical problems," Leonard says. The population served is transient and often difficult to find.
"Of the members the health plan has been able to locate, 100% have chronic medical conditions; 75% have mental health issues; 72% have medical, mental health, and substance abuse issues; and 30% are homeless," Leonard says.
"We collaborate with community organizations, shelters, safe houses, churches, mental health facilities, and community providers to locate the members and enroll them in the program," Leonard continues.
The program employs a peer review specialist, a community liaison who has personal experience with some of the issues faced by members in the program. She helps locate participants identified for the program and helps connect them to community resources.
When case managers make contact with a member selected to participate in the program, they arrange to meet them at a safe location, which may be the beneficiary's home, or it may be a fast-food restaurant, a laundromat, or another location.
Using a laptop computer, the case manager completes a detailed assessment which gathers information on biological risks, psychological functioning, social circumstances, and experiences with the healthcare system. The assessment has drop-down boxes in each area, saving the case managers time from typing in all the information.
The assessment typically lasts one to two hours, and it often takes several visits for the case managers to complete because of the attention span of the clients.
When the assessment is complete, the software tool creates a detailed care plan covering every aspect of the patient's needs. The care plan is color-coded to identify areas that need attention and indicate priorities.
If a portion of the tool is green, it means that patient has no risk. Yellow means slight risk and the component should be monitored. Orange designates a moderate risk and calls for action. Areas in red indicate a serious risk that requires immediate intervention.
"The color-coded tool identifies areas that need attention first and helps case managers set priorities when they develop a care plan. The tool was developed by case managers who helped program it to follow the same thought patterns and follow the same care guidelines as a case manager would. The tool helps them work more efficiently and in a more timely manner," Leonard says.
Case managers can print out the plan and share it with the patient, the caregiver, and the primary care physician. "They use the plan as they work with the patient to solve primary problems and set goals and interventions over time," she adds. "The case managers complete a reassessment every six months or after a major event like a hospital or an emergency department visit," she says.
The Westchester Cares Action Program team includes a RN who runs the program, two nurse case managers, a social worker case manager, two bachelor's prepared intensive care coordinators who have experience working with the Medicaid population and assist the clinical staff, and the peer review specialist.
The team has undergone extensive training on using the tool, motivational interviewing, safety issues, safe driving instruction, and discovering and using resources appropriately.
Leonard sees the program as a way to promote collaboration between the health plan and providers to jointly manage the care of patients. "We see it as a vehicle for us to do the front-end work of assessing patients and give the care plan to the providers and their on-site case managers. It's a value added for what health plans can do," says Leonard.
"Physician offices and health centers are moving toward having on-site case managers, but they are limited to coordinating care for people who come through the door," Leonard points out. "This tool takes too long for a doctor to use it. Health plan case managers complete the assessment and share the plan with the provider," she says.
For more information, contact Margaret Leonard MS, RN-BC, FNP, senior vice president for clinical services at Hudson Health Plan, Tarrytown, NY. E-mail: mleonard@HudsonHealthplan.org.