MMA SRC #10, Attachment 1: Care Coordination … 08/MAGELLAN...and information used by the TruCare clinical documentation system development team. The care coordination program incorporates

MMA SRC #10, Attachment 1: Care Coordination Program Description


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MAGELLAN COMPLETE CARE OF FLORIDA

Care Coordination PROGRAM DESCRIPTION

2017


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Florida Magellan Complete Care Care Coordination and Complex Case Management Program

Updated: March, 2017

Table of Contents Introduction ......................................................................................................................................................... 3

Element A: Population Assessment ................................................................................................................... 17

Element C: Identifying enrollees for Complex Case Management .................................................................... 18

Predictive Modeling and Risk Stratification ..................................................................................................... 19

Element D: Access to Case Management .......................................................................................................... 21

Element E: Case Management Systems ............................................................................................................ 22

Health Information Systems for Complex Case Management ........................................................................ 22

Element F: Case Management Process ............................................................................................................. 23

Multidisciplinary Team Roles ......................................................................................................................... 24

Assessment and Care Planning ......................................................................................................................... 27

Additional Care Coordination Program Considerations ..................................................................................... 33

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Introduction Magellan Complete Care of Florida (Florida MHS, Inc. d/b/a Magellan Complete Care or “MCC”) was created for the sole purpose of developing, delivering and managing state-of-the-art integrated medical and behavioral health services for individuals with serious mental illness (SMI). All aspects of the MCC of Florida Care Coordination program have been reviewed against State, Federal, and Accreditation requirements with enhancements made to better meet the enrollees’ needs. Since the launch of the MCC of Florida’s Specialty Health Plan in July of 2014, our dedicated care coordination and medical teams have focused their efforts on fully understanding the unique needs of a very complex population. We successfully launched our clinical programs and have continued to review, enhance, and hone our clinical program approaches based on the needs of the population. The current MCC of Florida membership continues to present with a variety of complex medical, behavioral health, and psychosocial conditions with populations ranging from maternal, pediatric/adolescent, and adult to end of life situations. In addition, a segment of our membership has continued to present with ultra high risk needs and situations, resulting in the need to further develop targeted and focused clinical programs. Examples of these enhanced programs include, Sickle Cell Disease, High Risk Pregnancy, High Risk Diabetes, Mood Disorders, Schizophrenia, and Congestive Heart Failure. Populations with SMI and with co-occurring and comorbid chronic conditions carry a disproportionate illness burden and pose significant challenges in overall stabilization and management. Our model of care is built upon the principles of:

• Medical, behavioral, and psychosocial integration • Recovery and resiliency • Self-management and self-directed care • Evidence-based medical and behavioral health care • Transparency • Shared decision making • Ensured access to care • Case management • Care transition management • Disease management, condition management, and population health approaches • Health and wellness prevention

The terms enrollee and member will be used interchangeably throughout this document. This document describes our overarching care coordination program and approach. Separate and detailed Utilization Management, Behavioral Health, Maternity, Childhood Check Up (CCHUP), Behavioral Health, Integrated Health Home, Disease Management, and other condition specific program documents have been developed as an adjunct to this document. MCC of Florida has developed a library of policies, procedures, and process flows which compliment the care coordination and case management approaches. Care Coordination support, utilizing the case management process, is essential for anyone who is accessing health services, regardless of the services being physical health, behavioral health or a combination of both. By partnering with individuals to assist them in managing their social, behavioral and physical health needs, MCC can break the harmful and costly cycle of inappropriate and costly emergency room (ER) visits, avoidable inpatient admissions, and unnecessary or duplicative medical costs overall. To avoid use of unnecessary acute care services, the Care Coordination team provides enrollees with education on identifying triggers and healthy ways to manage away from escalating to crisis levels; partner and work with them on not only educating them on how their health improves functioning but also on how it reduces exacerbation of mental health symptoms; and working closely with their behavioral health provider to increase services if it is deemed medically necessary to prevent hospitalization. The MCC Care Coordination team integrates HEDIS, preventive health, and screening educational activities in its daily work with enrollees. MCC’s focus and expertise of a fully integrated behavioral and physical health model, sets our

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health plan apart as a leader in the successful management of a very complex enrollee population. An essential component to the success of the integrated model is the need to integrate and collaborate with community agencies and providers on an ongoing basis. MCC strives to achieve the least amount of disruption to the enrollees’ existing support system. To support this, MCC collaborates with these community supports as an extension of the existing enrollees’ care team.

The Integrated Health Neighborhood (IHN) customizes MCC of Florida’s model of care (MOC) by region. MCC of Florida’s goal to improve members’ care, quality of life and health outcomes can only be achieved within the context of where the members live – within neighborhoods and communities. Our IHN team members live and work within the communities where our members reside. These team members have first-hand knowledge of community strengths, resources, services, and service gaps. IHN team members include Integrated Care Case Managers (ICCMs), Health Guides, Peer Specialists, and Community Outreach Specialists supported by Housing Specialists, Employment Specialists, Clinical Pharmacists, Medical Directors, and others. We created the IHN concept where relationships and collaborations with community partners enable us to effectively coordinate care with the community supports and services the member knows and trusts and the provider delivery system can easily access. The IHN is MCC of Florida’s vehicle to drive close collaboration with community partners, allowing us to customize care for our members, and to provide a seamless, one-stop system of services and supports. The IHN model naturally bridges language and cultural barriers and more effectively and efficiently facilitates access to services to support our members and families where they live, work and play. In rural areas, the IHN has the ability to utilize the latest Telehealth and Telemedicine techniques to ensure that members residing in rural areas receive the care and services needed at all times. Virtual health care applications which members can access at local libraries, agencies, and/or health care offices are also utilized.

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We comply with and have incorporated within our Model of Care, AHCA’s clinical program requirements, applicable NCQA Standards, and applicable State and federal regulations and requirements. Our ICCMs utilize both the Case Management Society of America’s Case Management Standards of Practice and National Association of Social Work Case Management Guidelines.

Our MOC reinforces and prioritizes recovery, stabilization, health maintenance, optimal safety and quality, and independence through partnering with the member, their natural supports and providers. Our recovery expertise and sound evidence based practice approaches have been utilized in the development of our Behavioral Health program approaches, including best practice protocols in the area of addiction and recovery services. We emphasize a whole person approach across the spectrum of care and service needs. Our provider network partnerships are built with this goal in mind, consisting of traditional healthcare providers, behavioral health specialists, LTSS, and other community agencies and resources with a shared commitment to person-centeredness, evidence-based treatment, robust communication, and teamwork.

We believe individuals should have a choice in where they live and in the services they receive. These same individuals are at the center of and participate in their respective care planning activities. Our innovative care coordination approach is built on a platform of historically successful performance

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promoting the use of high quality services and cost-effective approaches that assist in developing person-centered care plans. We offer access to evidence-based services, robust communication, teamwork, and a culture of “going the extra mile.”

Based upon our experience serving special needs populations, we understand the investment needed in person-to-person relationships especially between enrollees and their care team. Through these relationships, our care team seeks to fully understand why an individual may be in crisis and we identify strategies to assist them on their path to higher functioning. We invest our resources in making an impact, one enrollee at a time; by taking a highly individualized, high touch, community based approach to Care Coordination. Our care teams leverage community supports and institutions, such as churches, existing community agencies, advocates, and faith-based organizations, as part of the solution. The value we place on investment in human relationships with our enrollees fundamentally changes and challenges the common construct of how we think about health care, wellness, and how people become healed.

Using an integrated, high touch, team-based approach, we address the full continuum of care and services simultaneously rather than in a linear or sequential manner. This allows us to continually adjust our interventions based on evolving enrollee needs and circumstances. The elements of our approach to the management of high need enrollees includes identifying health risks, biopsychosocial, and chronic care needs, assessing the enrollee, designing a plan of care to proactively address the most immediate needs, engaging the interdisciplinary care team and focusing on effective and comprehensive transitional care from inpatient to other settings. As indicated, we link these elements with appropriate use of Health Information Technology.

Core Focus and Development of the Program

The key evidence used to develop MCC’s Integrated Care Coordination Program is based on the Case Management Society of America’s Standards of Practice and the National Association of Social Work Case Management Guidelines. In addition, the Florida clinical teams utilize the long standing expertise within the national Magellan Behavioral Health service models, the National Practice Guidelines as approved by the Magellan Medical Advisory and Medical Director groups, and the practice guidelines and information used by the TruCare clinical documentation system development team. The care coordination program incorporates the current NCQA Complex Case Management standards and State and Federal case management practice guidance. Care Coordination for All Members Consistent with our Integrated Health Neighborhood approach, MCC of Florida’s care coordination program is person-centered, community-focused/where the member lives, and evidence-based. Our program is built upon our experience coordinating care for complex members with multiple chronic physical and behavioral health conditions. As we leverage our experience serving members who have complex and multiple chronic conditions, we have the knowledge and resources to support a variety of populations and services. Our Integrated Care Case Managers carry out the case management process and have the background, credentials and experience to assist members with their physical, behavioral, and social healthcare needs. The core of our care coordination program is the person-centered planning process. A key component is member choice and control. We employ and assign experienced ICCMs to carry out the case management process, working with the SMI population. These ICCMs are educated and trained in all aspects of case management practice and in caring for individuals in specialized populations along with person-centered assessment and planning principles, processes, and requirements. The ICCMs are skilled

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in establishing trusting relationships where the member is the center of the process along with the support of the member’s family, caregivers, and providers. The ICCM collaborates with these stakeholders to complete the assessment and care planning process, ensuring the greatest degree of success to meet the member’s goals. Our ICCMs demonstrate passionate and dedicated care for our vulnerable populations. Our ICCMs and the other members of the care team live in the communities where members live and have relationships with local providers and community resources. MCC of Florida has partnerships with the local community resources in all areas of Florida. Members and providers have access to the care coordination team and ICCMs 24 hours each day, 7 days each week. MCC of Florida operates a call center which has a single 24/7 toll-free number for assistance and includes a warm transfer to the CareLine. As part of business continuity, call center staff can work remotely in case of unplanned events like natural disasters. The call center has trained staff operating the telephone lines during regular business hours to assist members with changing providers, obtaining transportation, scheduling interpreters in 200 languages, accessing an ICCM or care team member, and obtaining needed services. Member Communication MCC of Florida provides communication and education on available services and community resources to the member from numerous sources including the ICCM, other members of the care team and customer service, the Member Handbook, the welcome call to new enrollees and the documents distributed during a face to face visit. The ICCM ensures that the member understands the information provided in the care plan, including available services and community resources. MCC of Florida also develops the communication and education materials based on input from focus groups and the Enrollee Advisory Committee. Member materials are reviewed to ensure consideration of a member’s physical and cognitive skills, and level of literacy, focusing on cultural sensitivity and cultural appropriateness for all individuals. The ICCM supports the member with self-management skills to access care by arranging for peer support and education. The ICCM also assists in accessing community support agencies who offer education and training on self-management skills. MCC of Florida provides an ICCM or other support staff member who meets with the member either face-to-face or telephonically, to review the care coordination program, contact information, including name and information for reaching the ICCM and other members of the care team. This same information is included in the member Welcome Kit received upon enrollment. The ICCM and care team members instruct the member on placing the contact information in an easily accessible place for the member, family, and caregivers. MCC of Florida works closely with the member to ensure that the member agrees with the ICCM and care team member assignment. For health plan-initiated changes, the current ICCM or care team member notifies the member with the new ICCM or care team member contact information. When the member requests an ICCM or care team member change, MCC of Florida assigns a different ICCM or care team member who contacts the member and provides contact information. When appropriate, the new and previous ICCMs or staff members make a joint visit to ensure a smooth transition. As described earlier, MCC of Florida employs community-based staff who reside in and near the same communities as members. The staff have existing relationships and contacts in the community, which often helps in successfully locating members. We also mail “Trying to Reach You” letters to the home

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address emphasizing the importance of contacting us to continue receiving services. We monitor utilization management and claims data for information on the member if they are accessing ERs, filling prescriptions at pharmacies, or admitted to hospitals. In other markets, MCC of Florida has utilized a company, Integra, who specializes in locating hard-to-find individuals. The Integra Team has a solid track record of collaborating with the MCC care coordination teams in successfully locating members. The ICCM and care team members use a person-centered approach engaging members about available services and supports to assist in achieving optimal health, wellness, and self-management goals. The ICCM and care team members also explain the support provided to the member for self-direction and self-management. However, we understand from previous experience there will be members who decline care coordination services. The ICCM will explain our role is to support the member in accessing services and supports to meet their goals. The ICCM provides the member with contact information with each interaction. Provider Notification MCC of Florida identifies providers through historical claims data or by the member informing the ICCM or care team member during the initial visit. The name of the ICCM or care team member, how to contact them, and when they are available is given to the provider whenever possible. Staff also provides information on the alternative resources if the ICCM is unavailable, as noted above, and when there is a change. Enhanced Care Coordination for a Vulnerable Population: A Paradigm Shift

The MCC of Florida model of care has continued to evolve to further expand and define services to meet the specialty needs of our highest risk members. We have recently implemented a paradigm shift in our care coordination and case management approaches, focusing on the establishment of complex case management (CCM) and disease state specialty teams. These teams focus on assisting members with both short and long term care coordination and case management activities, along with reducing unnecessary resource utilization and reducing preventable admissions. The disease state specialty teams are focused on the following disease states: High Risk Diabetes, High Risk Pregnancy, CHF, Sickle Cell, Schizophrenia and Mood Disorders. The teams are equipped with analytics and information which guide focused case management efforts in addition to emergency department diversion (EDD) activities. For our highest risk members (Ultra High Risk Level), we have decreased the ICCM’s caseloads to 1:25 creating the capacity for individualized clinical activities including:

• Completing In-home assessments and evaluating the home environment • Increasing coordination with Medical Management to focus on skilled and unskilled care • Additional time for ICCMs to accompany members to PCP visits and collaborate on plan of care • Improving coordination with Magellan Rx to evaluate and improve medication adherence • Coordination with partner vendors for DME and Home Health Services • ICCM will be able to further lead discharge planning process and complete post discharge follow-

up • Assisting homeless members to access short/long term housing programs

MCC of Florida serves the most complex populations, including those members who may present with a primary diagnosis of SMI, severe emotional disturbance (SED), and substance use disorders (SUD), and who also have complex medical and behavioral health issues. Members that have multiple chronic conditions are designated as high-risk members and receive complex and enhanced care coordination

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services. An essential element to enhanced care coordination is using an assessment and planning process with the member at the center. Our staff are culturally competent and prepared to collaborate with all members regardless of their levels of health literacy or any communication, language and cognitive barriers. Despite these barriers, the ICCM ensures the member can actively participate in the assessment and care planning process with the necessary supports. The ICCM assists the member in defining life goals and services needed to reach these goals. The ICCM ensures the member, family, and caregivers all participate in developing a care plan to meet the member’s goals. The ICCM also supports members with very complex and multiple chronic conditions in understanding the multiple services and providers involved in the individual’s care. We build highly-specialized teams of subject matter experts dedicated solely to the engagement of vulnerable populations. We differentiate ourselves by not only describing and talking about our clinical model, but truly carrying it out. MCC of Florida does not just “talk the talk” but we “walk the walk” at all times. The ICCMs and care team members have extensive knowledge and experience with the available community resources to support specific populations. The ICCMs and care team members leverage their knowledge of providers, community supports (such as churches, existing community agencies, advocates, faith-based organizations, and child services agencies), as part of the solution. We invest in making an impact, one member at a time, by taking a highly individualized, high touch, community-based approach to enhanced care coordination. MCC of Florida’s care coordination program uses an integrated, high touch, team-based approach. We address the full continuum of care and services simultaneously rather than in a linear or sequential manner. This allows us to continually adjust the care plan based on evolving member needs and circumstances. The elements of our care coordination approach include identifying health risks, using person-centered planning to work with the member in identifying goals and services needed, partnering with the member to develop a care plan, engaging the interdisciplinary team, and focusing on effective and comprehensive transitional care from inpatient to other settings.

Staffing and Organizational Alignment

The Care Coordination team is led by the Vice President, Health Services in conjunction with the Chief Medical Officer (CMO) who collaborate and oversee clinical/quality initiatives and manage medical policy, clinical care guidelines, utilization parameters, and quality assurance activities. The CMO actively participates in and coordinates medical oversight and acts as a principal advisor to enrollee population’s care treatment plans and clinical programs.

Behavioral and Physical Health Medical Directors serve the critical role of providing clinical and Care Coordination support, assistance with team management as well as evaluating requested services. The Medical Directors work in conjunction with the Care Coordination team ensuring that the highest quality of care is delivered at the most appropriate service level.

The senior level and front line supervisory Care Coordination leadership staff has a wide variety of clinical and/or health plan expertise and possess various certifications in areas such as managed care, case management, chronic care, behavioral health, counseling, and quality. Directors and Managers are responsible for managing daily operations and oversight of the front line Care Coordination staff. The Directors and Managers have direct responsibility for staff development, training and orientation. In addition, they are responsible for driving daily initiatives promoting achievement of enrollee health outcomes, satisfaction, designated quality and HEDIS initiatives, and cost containment efforts.

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The front line Care Coordination team consists of clinical and non clinical subject matter experts, including social workers, registered and licensed practical nurse case managers and non-traditional providers such as peer specialists and health guides. In addition, the MCC team works with community partners as an extension of the support provided to the enrollee. MCC understands the importance of collaborating with the enrollees’ existing community supports and providers on an ongoing basis.

Each level or segment within the care coordination program and each team supporting the same is configured to have a caseload that meets the complexity of the stratification along with the complexity of the individual enrollees. MCC’s multi-disciplinary team approach provides greater band width and support to the enrollee and as stated earlier, the configuration is based on stratification complexity and enrollee complexity. The risk level segments will be described in more detail within this document. The wellness, prevention and disease management programs are built based on current best practice and approved national guidelines and are fully integrated within the different levels of the care coordination program. Innovative outreach approaches and technology are used to maximize enrollee engagement utilizing the enrollees’ preferred method of communication. Existing community supports and programs are tapped as an additional ongoing support to these enrollee outreach approaches. MCC supports a flexible approach to enrollee engagement and care coordination, welcoming existing support from successful community programs. The care transitions and emergency department follow up program activities are integrated within each area/level within the care coordination program. The MCC care transitions and emergency department follow up activities are based on a blend of key components from the National Transitions of Care Coalition and Eric Coleman Care Transitions Program®. Outreach and enrollment activities are based on enrollee need. Specific criteria have been developed and are used by each of the enrollee facing areas to offer ease of placement and referral to the appropriate care coordination program.

Care Coordination Program Framework

MCC’s care coordination program embraces a proactive population health concept that:

• Emphasizes sound identification of enrollee health status and enrollee needs • Delivers effective, compliant, high quality and cost effective services • Monitors, measures, and improves enrollee health outcomes

The care coordination program includes three major functional elements identification, engagement, and achieving outcomes.

1. Identification involves processes to identify enrollees who are likely to benefit from care

coordination services ranging between low and high/ultra high risk/complex risk levels. Referrals for care coordination services are received from both internal and external sources. Predictive modeling activities help identify enrollees who may potentially benefit from specific care coordination programs. In the absence of predictive modeling, triggers have been developed which are used by the care coordination teams when evaluating the services an enrollee may need. The care coordination risk stratification and health assessment activities are focused on conditions prevalent to children, families, aged, blind, frail, chronically ill and disabled populations. Based on results of defined identification and/or assessment processes, the team ensures a consistent enrollee assignment strategy. These processes target the most appropriate level of care coordination and case management services, including the low/monitoring, population health/disease management, moderate case management, specialty teams, and ultra high risk/complex care coordination programs.

2. Engagement includes outreach involving the enrollee in all aspects of the care coordination and case management process, including initial and ongoing assessment, coordination/collaboration,

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setting prioritized goals, and interventions including face to face visits in some instances. The care coordination team is responsible for contacting the enrollee, the enrollee’s family/caregiver/legal guardian, the treating physician, and other providers as needed to collaboratively address identified health and care coordination/case management needs. Upon referral or during outreach activities, the care coordination team ensures that key stakeholders are included in offering ongoing input into the assessment and care planning process as appropriate for each enrollee risk level. Further, protocols are in place for surrogate decision making if the enrollee is not capable of making his/her own decisions, but does not have a legal representative or authorized representative available. For enrollees who are difficult to locate, the ICCM or Wellness Specialist will refer the member to the Health Guide or ICCM in the field to try and find the enrollee. We carry out a no stone unturned approach to finding enrollees either through the claims we have received such as RX, PCP, Specialists, etc., and reach out to find enrollees ongoing. In addition, our care team is able to utilize a contracted vendor, Integra, who specializes in locating difficult to find members. To date, Integra has been very successful in assisting our care team in locating members who are difficult to find.

3. Outcomes involve the measuring and reporting of defined clinical, preventive health, enrollee

satisfaction, operational, and financial results of the care coordination program. The outcome measurement activities assist in validating the effectiveness of meeting enrollee health and wellness needs, effectiveness of the program’s activities, and assists with meeting accreditation and compliance requirements. Measuring outcomes allows the team to appropriately focus the enrollee interventions where they will make the most impact on the enrollee’s health and well being. In addition, we are able to review and measure an individual member’s care plan goals as met or unmet.

Care coordination is defined as the organization of support, monitoring, and assistance for enrollees in navigating and engaging with the health care delivery system, including steps taken to ensure each enrollee receives preventive, medical, behavioral, and psychosocial care/services consistent with their needs and care which is integrated across all providers and community supports who are treating and supporting the enrollee.

MCC provides enrollees with care coordination and case management support through a team-based approach, including outreach to the enrollee’s providers, community supports, and community agencies. Additionally, it provides programs that meet enrollees’ special needs, including disease management, peer support, integrated pharmacy management, care transitions, preventive health, pediatric/adolescent care, and high risk maternity management. Complex case management is provided for the highest risk sub population and the medically complex/medically fragile, as further described in this document.

Complex case management is defined as the intensive coordination of care and services provided to a subset of enrollees who have multiple health care needs, or who have experienced a critical event or a diagnosis that requires the extensive or prolonged use of resources. MCC uses a holistic and integrated approach to deliver case management services to those individuals with complex behavioral and physical health care needs. MCC will make repeated attempts to engage all identified high risk enrollees in our complex case management program. We offer an opt-out complex case management program where all eligible enrollees have the option to participate or decline participation.

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If the enrollee decides to opt out, MCC educates the enrollee of the benefits of the program to ensure that the enrollee makes a fully informed decision. We also inform enrollees that if in the future they change their mind, they can be re-evaluated for enrollment to the program. The goal of complex case management is to help enrollees regain optimum health or improved functional capability, in the right amount, in the right setting and in a cost-effective manner. It involves comprehensive assessment of the enrollee’s health status; determination of available benefits and resources; and development and implementation of a case management plan known as the care coordination plan, with performance goals, monitoring and follow-up. A detailed desktop procedure has been created for clinical staff to reference, as needed. At any time, the primary case manager can utilize clinical judgment to determine the enrollee risk level and appropriate case management program enrollment. The Member Claims & Predictive Model Engine diagram (Attachment 1) portrays the criteria and entry points for each of the different Care Coordination Program Risk Level Segments.

Care Coordination Program Risk Level Segments:

Specific Program Risk Level Complex Case

Management (Yes/No)

Primary Care Coordination Team Member Assigned to Member

Services Provided Identified By

Enhanced Care Coordination

Ultra High Risk

Yes ICCM (Caseload of 1 ICCM to 25 members)

(In identified regions) Intensive, community based, face to face case management services

Member Claims/Predictive Modeling, Referrals, and Identified Disease States

Disease State Specialty Team

High Risk Yes ICCM (In all regions/Statewide)

Member Claims and Specialty Condition(s): CHF, High Risk Diabetes, Mood Disorders, Schizophrenia, High Risk Pregnancy, and Sickle Cell Disease

Short Term Case Management

High Risk Yes ICCM with support of other team members (Health Guide, Peers Support, etc.)

(In all regions) Short term case management for an identified, short term need – easily resolved in a short period of time

Referrals and warm transferred calls

Monitor Risk Moderate Risk

No Care Coordination Health Guide

(In all regions) Monitoring and outreach to identified members - once engaged, referral can be made to other programs/services as needed

Member Claims

Population Health/Disease Management

Low Risk No Disease Management/Population Health Team

(In all regions) Disease Management,

Member Claims, Disease Management Conditions (Non High

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Health and Wellness Programs, HEDIS Outreach Campaigns, and Web Based Programs

Risk Diabetes, HTN, Asthma, and Cancer), gaps in care reports, and other identified populations (non high risk maternity, Childhood Check Up, Healthy Behaviors, etc.)

No Case Management

N/A No N/A Member refuses case management or care coordination services

N/A

Distinguishing Factors of Complex Case Management:

• Degree and complexity of illness or condition is typically severe • Level of management necessary is usually intensive • Amount of resources required for enrollee to regain optimal health or improved functionality is

typically extensive MCC provides complex case management services to help enrollees achieve their optimal health and recovery and become more self-directed in managing their health care. Complex case management services are delivered by MCC’s care coordination team which manages enrollees identified for complex case management and includes Integrated Care Case Managers, a clinical Pharmacist, Peer Specialists and Health Guides. The enrollee, the enrollee’s family supports, and the enrollee’s providers are encouraged to be part of the care coordination team and to be active participants in the case management process which includes plan of care development. Integrated Care Case Managers are registered nurses or masters level social workers or mental health professionals who provide systematic enrollee assessments and coordination of care and services using evidence-based clinical guidelines (EBG). They are available to coordinate complex care arrangements and connect high risk enrollees to the services they need while maximizing the use of their benefits.

Integrated Care Case Managers assist high risk enrollees who are enrolled in the complex care program proactively obtain the care and services needed to avoid the unnecessary or inappropriate utilization of more intensive health care resources. This is accomplished by assessing and re-assessing their needs, providing personalized health information, supporting Care Coordination among multiple behavioral and physical health providers, and connecting enrollees to the appropriate resources. Integrated Care Case Managers act as a liaison between the enrollee and providers, ensuring the enrollee is receiving proactive behavioral health, medical and specialist care as needed.

MCC has developed three levels of complex case management services including Ultra High Risk (Enhanced Care Coordination) and High Risk. Enrollees can also be identified as High Risk through the Health Risk Assessment (HRA) process and scoring, utilization reports, direct referral, and by having special conditions. Ultra High Risk/Enhanced Care Coordination: This program segment is determined by the MCC of Florida Member Claims & Predictive Model Engine. This CCM membership is identified by the predictive model as likely to admit in 90 days. The members within this segment are also diagnosed with one of the disease states described in the disease state specialty segment below.

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High Risk/Disease State Specialty Care Coordination: This program segment is determined by members having a diagnosis of one of the conditions listed below. In addition, the members in this segment have 3 + hospital admissions within a 12 month period.

• Mood disorders • Schizophrenia • High Risk Diabetes • Congestive Heart Failure • Sickle Cell • High Risk Pregnancy

Short Term Case Management and Monitor Risk Care Coordination: These program segments are determined by members having 3 + hospital admissions within a 12 month period, but do not have one of the diagnoses listed above within the Disease State Specialty segment. Based on clinical review, the team determines if the member is pursued/requires short term case management or is not pursued and is placed within the monitor risk program where the member is monitored for any and all utilization or changes in status. Population Health/Disease Management: For members who are eligible for enrollment into one of these program, the members will be offered health and wellness services and education. The programs are offered to all MCC of Florida members offering access to health and wellness materials, education, and seasonal campaign outreach programs. If a member is determined to have no case management needs, they will not receive case management services. Complex Case Management Program Assignments Case assignments are team based and assigned as follows:

• All new MCC enrollees are auto-assigned to a Regional Clinical Care Manager based on the zip code/region in which they supervise when the eligibility file is received from the Agency for Health Care Administration (AHCA).

• Case assignments/Health Risk Assessment (HRA) completion: Assignments are completed by the Clinical Care Manager to one of their team’s ICCMs. The Clinical Care Manager completes a task in TruCare to the individual ICCM. Each enrollee receives at least 3 initial outreach attempts by telephone to complete the HRA. If the enrollee is not reached, a letter is sent to the enrollee to let them know that MCC is trying to reach the enrollee to complete a Health Risk Assessment.

• Case assignments for special conditions: Assignments are completed by the Clinical Care Manager or Director based on areas of specialty. A task is set in TruCare to the individual user’s queue notifying them of the assignment.

• MCC staff work diligently to obtain accurate enrollee contact information to ensure successful enrollee engagement.

• The ICCM becomes case owner of the above cases, adds the Health Guide to the case, and enrolls the enrollee in the Complex Case Management Program.

• The Case Owner is changed according to case assignments and the Case Type value is updated to ‘High Risk’ or ‘Ultra High Risk’

For enrollees who have justice system involvement, MCC works with and creates linkages to pre-booking sites for assessment, screening or diversion related to behavioral health services based on enrollee need.

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If MCC is unable to engage the enrollee, MCC staff looks for claims from providers to determine if an alternate address or phone is available to outreach to the enrollee. If no information is found or there is no updated enrollee phone number or address, MCC staff set a task to attempt re-engagement within 90 days. If the enrollee calls MCC for assistance or receives services at an inpatient unit or emergency room, MCC staff obtains an updated phone number and address to attempt engagement again. If the enrollee meets criteria for complex case management and the ICCM is unable to engage them after 3 attempts in 14 days, the case is reviewed to determine if the enrollee requires a step down to the ‘Monitor Risk’ care coordination program segment.

As mentioned earlier, a key element within the Care Coordination Program Framework is the engagement process which includes outreach involving the enrollee in all aspects of the case management process, including initial and ongoing assessment, coordination/collaboration, setting prioritized goals, and interventions including face to face visits in some instances. The Care Coordination team is responsible for contacting the enrollee, the enrollee’s family/caregiver/legal guardian, the treating physician, and other providers as needed to collaboratively address identified health and Care Coordination needs. Upon referral or during outreach activities, the Care Coordination team ensures that key stakeholders are included in offering ongoing input into the assessment and care planning process as appropriate for each enrollee risk level. Further, protocols are in place for surrogate decision making if the enrollee is not capable of making his/her own decisions, but does not have a legal representative or authorized representative available. For enrollees who are difficult to locate, the Case Management or Disease Management team member will refer them to the ICCM or Health Guide in the field, as appropriate, or connect with community partners to try and locate the enrollee. We carry out a no stone unturned approach to finding enrollees either through the claims we have received such as RX, PCP, Specialists, etc., and reach out to find enrollees ongoing.

As appropriate, MCC partners with Providers, vendors, and community-based organizations to locate hard to reach enrollees and involve them in the engagement process. Magellan Complete Care has developed flexible and innovative community partner collaborative agreements to maximize enrollee outreach and ongoing engagement. These relationships enhance enrollee engagement without duplicating efforts. Additionally, for transient enrollees with behavioral health needs, Magellan Complete Care partners with Community Mental Health Centers to identify, locate and engage enrollees.

As described earlier, MCC provides non complex case management services for those enrollees who do not meet the higher risk, complex case management program criteria. Enrollees receive initial outreach and screening upon enrollment to the health plan. Once an enrollee is assessed, a care plan will be developed for the enrollee. All enrollees receive targeted mailings and health prevention information via mail, telephone, or the web portal. Health and wellness programs are accessible to all enrollees and designated HEDIS outreach activities are provided to the membership as defined in the HEDIS and quality strategy documents. Enrollees who have one of the four Disease Management conditions, are followed by the Wellness Specialists who prioritize the needs of the membership based on the condition (Asthma, Hypertension, Diabetes, and Cancer). The population based programs are monitored and managed by a Health Guide who collaborates on an ongoing basis with enrollee services and the case management team to ensure that appropriate targeted outreach and campaigns are being conducted. Technology and automated dialers, etc., are used to augment the engagement of the MCC membership. MCC’s Integrated Care Model and the ICCM Role

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Integrated Health Home Model In 2017, to more effectively integrate physical and behavioral health, MCC Florida is designing, developing, and plans to implement an enhanced comprehensive clinical approach for members, using a biopsychosocial model that incorporates and coordinates inpatient hospitalization, partial hospitalization, intensive outpatient, outpatient and coordinated wraparound services that include a spectrum of aftercare programming. This model is currently called the “Integrated Health Home Model.” One component of this comprehensive initiative will be directed toward those members with frequent hospital readmissions. We are calling this component the “Hospital Home Program” and, although applicable to both physical and behavioral health admissions, it is a natural extension of MCC’s BH Hospitalist program. When a member is assigned to a “hospital home,” the member will be empaneled to that facility. In most instances, the Hospital Home will also be the hospital at which MCC has a hospitalist. This is particularly important for BH admissions. All other hospitals in the catchment area will be notified that the member is assigned to a “hospital home. The facilities will be instructed to stabilize the member and coordinate and send the member, by ambulance, to the hospital home.

Once at the hospital home, specific clinical protocols will be initiated. A substance abuser, for example, will be considered captive to intervention from the attending, the hospital staff, and MCC’s case managers – all integrated through the utilization management professional for that admission. The intention is to treat the member with appropriate medications and engage the member with a substance abuse program. Element A: Population Assessment

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Assesses the characteristics and needs of its enrollee population and relevant subpopulations. Reviews and updates its CCM processes to address enrollee needs, if necessary. Reviews and updates its complex case management resources to address enrollee needs, if necessary. Enrollees in Magellan Complete Care’s complex case management programs typically have co- morbidities and behavioral health needs that can significantly diminish their quality of life, as well as their ability to adhere to their treatment plans. Case managers use health plan and care coordination team resources, such as health guides, peer specialists, clinical pharmacists, medical directors, and disease management programs (e.g., asthma, diabetes, etc.), to support the management of the care of enrollees with multiple and complex conditions.

Magellan Complete Care, at a minimum, annually assesses the characteristics of its enrollee population and relevant subpopulations to identify enrollees for complex case management such as:

• Individuals with disabilities and SMI • Low income • Dual eligible • Multiple chronic conditions • At- risk ethnic, language or racial groups

MCC reviews and annually updates its complex case management processes and resources to address enrollee needs if necessary. With this assessment, enhancements and adjustments were made to the Care Coordination program components in order to better meet the enrollees’ needs.

Population Assessment Map

The annual Health Risk data for MCC is reviewed as a part of the population assessment process. This report provides MCC with an overview of the demographics, health status, specific lifestyle risks and

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disease burden of its population. After reviewing the Health Risk Report, programmatic adjustments (i.e. staff resources or processes, job training, cultural competency updates, etc.) to the complex case management and other care management programs are made to address enrollee or population needs. Data for this report is obtained from the following sources:

• Claims/encounter data: Claims data is used to identify enrollee demographics and those

who have a targeted diagnosis. • Pharmacy data: Pharmacy data is used to identify enrollees with certain chronic conditions,

such as diabetes or HIV/AIDS. • Health Risk Assessment data: The HRA is a proprietary assessment tool developed by

Magellan’s medical and behavioral health experts. This assessment is comprised of medical, preventive, behavioral, psychosocial, and lifestyle questions that are tailored to the SMI population. Enrollees self-identify whether they have any biopsychosocial risks such as issues related to living situation and social connectedness, or multiple chronic conditions.

• Lab results: Lab data is used to identify risk levels for enrollees in the population, based on certain lab result values (such as LDL, blood glucose and HbA1c test results).

• Information from clinical systems: Data from our electronic health information system (known as TruCare) is used to identify individual enrollees who have multiple or complex needs

• Information from enrollees and providers: Enrollees may self-refer or be referred by their provider into Magellan Complete Care’s complex case management program.

• Public health reports and data: Local, state and federal agencies provide data on health issues of the population including comparative norms and benchmarks.

The annual Health Risk data provides key information for prospective, strategic planning for the Care Coordination program. It informs of the resources needed for programs, including but not limited to staffing ratios, staff’s clinical qualifications, job training, external resource needs and community contacts, and cultural competency. Element C– Identifying Enrollees for Complex Case Management NCQA reviews documented processes and reports to evaluate the organization’s criteria and process for identifying enrollees eligible for complex case management using the identified data sources and reports demonstrating identification based on the sources. Enrollee identification is the initial process of complex case management. The initial step in identifying populations with complex case management needs is to identify specific populations which are at high risk for future acute care encounters, and/or have complex conditions and co-morbidities. Our program uses a combination of predictive modeling to identify enrollees with complex conditions and find the highest risk tier enrollees, ‘real time’ referral sources, and consistent criteria that recognize a potential complex case management opportunity.

The complex case management selection criteria consist of targeted diagnoses and situational criteria which indicate a potential catastrophic or complex enrollee whom may benefit from (complex case management) intervention. The review and evaluation of reports weekly, monthly or annually assist with the identification of enrollees for complex case management services. Criteria primarily used for highest risk tier identification include:

• Multiple chronic illnesses

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• Chronic illnesses that result in high utilization • Multiple ER visits (medical or behavioral health) • Multiple hospitalizations • Readmission within thirty days with the same/similar diagnosis • Transitions in care as the patient moves from one health care provider or setting to another • Polypharmacy utilization per quarter • Identification of medically complex/medically fragile children by the State

The most frequently managed clinical conditions or highest risk groups include but are not limited to:

• Serious and persistent mental illness, including schizophrenia and mood disorders • Diabetes • Congestive heart Failure • High risk maternity with complications • Sickle Cell Anemia

Predictive Modeling and Risk Stratification

MCC has licensed ImpactPro to enhance our predictive modeling capabilities. The tool has been modified by Magellan to incorporate behavioral health conditions, social support status and other issues that are unique to this population. The tool assesses future utilization, and assigns each person a likelihood of hospital admission and other health service utilization based on previous claims and other data, including enrollee reported information. The model relies on the use of a more robust data set than most models, including:

• Enrollment information (age, gender), • Medical and behavioral claims (diagnoses, cost of care, events), • Outpatient pharmacy claims, and • Selected Health Risk Assessment data.

In addition to identifying the top tier risk population on a monthly basis for possible complex case management, ImpactPro also identifies gaps in care that can be used to improve clinical care and outcomes and mitigate the risk of increased utilization.

The value of a predictive modeling tool is not just the identification of the top tier risk enrollees, but the interventions that can change that risk. MCC engages our SMI enrollees in complex case management by engaging treating providers in developing joint treatment plans, taking advantage of health plan supports available for SMI enrollees, such as Health Guides and Peer Support, and working with both physical and behavioral health providers to meet the enrollees’ needs. As described earlier, MCC has recently reviewed the current membership data to further assist the clinical team in understanding the needs of the membership and to plan for meaningful engagement. In addition, MCC has adjusted its disease management program to offer fully integrated condition specific outreach to all enrollee risk levels. A separate disease management program description describes these services in detail. The complex CM team provides the disease management services for their respective enrollees and are able to consult with the Wellness Specialists on an as needed basis. An example of the disease management model risk stratification is outlined below. Additional detail can be found within the dedicated disease management program descriptions, including, Cancer, Diabetes, Hypertension, and Asthma.

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Health Risk Assessment and Risk Stratification

An important step in improving outcomes for the SMI population is in the identification of individuals who have the highest risk needs for which gaps in care need to be addressed or closed. Due to the unique characteristics and challenges of the SMI population, we have found that risk stratification cannot be done solely through claims analysis, particularly when claims data are unavailable or there is a lack of an extensive history of claims. Additionally, there are critical components of information that can only be provided by self report from enrollees. These include health habits, living situation and social connectedness, which are all important predictors of outcomes for the SMI population. The ICCM utilizes clinical judgment and team input to assist with appropriate risk level assignment.

MCC uses a unique, SMI-tailored HRA that includes components that identify key areas of risks and needs of the SMI population. The core domains of the HRA include:

• Living Situation, • Hospital/Office Visit History, • Substance Abuse History, • Social Activity, • Physical Activity, • Preventive Test History, • Chronic Condition History, and • Rating of Health.

MCC’s HRA can be administered in person, electronically via the MCC website, or telephonically. Once MCC’s care coordination team is informed that an individual is enrolled in the health plan, staff reaches out to the enrollee through written materials and telephonically, to welcome them to the health plan. In addition, staff gather the HRA information as well as documenting the information gathered. Together, these tools are used for a baseline understanding of the enrollee’s recent health history and current needs. If enrollees prefer a face to face assessment, our staff will schedule a time to complete the assessment in person. Enrollees in an institutional setting receive a face to face evaluation, whenever possible. Our goal is to complete health risk assessment for enrollees within 30 days of enrollment. We utilize Health Guides and Peer Support Specialists to help locate individuals who are homeless or otherwise hard to find.

Responses to the HRA questions allow us to identify those enrollees who are at greatest risk based on critical elements collected through the HRA. Relying on a unique scoring system that assigns different values to higher risk elements, such as hospitalizations, ER use and presence of chronic conditions, we stratify the population based on self-reported behavioral health and physical health responses on the HRA. The risk level guides the level of optimal case management that addresses each person’s specific needs. Enrollees who are stratified as a potential complex case management enrollee receive additional clinical assessment to determine if they meet criteria for participation in the complex case management program.

Although the HRAs are compiled on an annual basis, they provide important insights to identifying complex case management enrollees. The HRA information supplements the monthly enrollee identification through our predictive modeling process and the ongoing, real-time identification through utilization management, disease management, and other referral sources.

The care coordination team works closely with the clinical call center and enrollee services teams to ensure that enrollee calls and outreach are being handled in the most efficient manner.

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Element D - Access to Case Management

The organization has multiple avenues for enrollees to be considered for complex case management services, including Health Information line (Nurse Line) referral, DM program referral, DP planner referral, UM referral, practitioner referral, and enrollee or caregiver referral

MCC believes in a “no wrong door” approach for enrollees to access CM services. Enrollees can be referred for any of the MCC care Coordination programs at anytime. Enrollees who experience a critical event or diagnosis receive timely complex case management services. To minimize the time between when an enrollee’s need is identified and when the enrollee receives services, MCC has multiple avenues for enrollees to be considered for complex case management services including, but not limited to:

• MCC nurses review information from enrollees or providers who contact MCC via the 24/7

telephonic CareLine. • Referrals received from MCC’s Disease Management program staff are documented in the

TruCare clinical documentation system Referrals are received, (phone or fax), from the enrollee’s provider.

• Communications/meetings occur monthly and as needed between Disease Management (Wellness Specialists), Utilization Management (UM), and Integrated Care Case Management to identify potential enrollees for complex case management.

• Referrals are received from hospital discharge planners to Magellan’s Health Services staff (phone, fax) to identify enrollees who have complex conditions requiring immediate complex case management through the transitions in care process.

• Data gathered from UM activities assist with the identification of enrollees who may benefit from complex case management. The data includes information on the utilization of emergency and inpatient care for ambulatory care sensitive conditions and readmissions.

• Enrollees or their caregivers may self refer (phone, face to face) to the complex case management program.

Information regarding how providers can refer an enrollee to complex case management can be found in the provider manual at www.MagellanCompleteCareofFL.com. The provider support specialist and other network management staff continuously educate providers on MCC complex case management including the different ways they can refer their patients to the program. This is accomplished through regular visits as well as regularly provided training sessions. Integrated Care Case Managers or their designees attempt to respond to a referral within the same business day, but no later than 48 hours after receiving the referral. Element E– Case Management Systems

The organization uses case management systems that support:

1. Evidence-based clinical guidelines or algorithms to conduct assessment and management. 2. Automatic documentation of the staff enrollee’s ID and date, and time of action on the case. 3. Automated prompts for follow-up, as required by the case management plan.

The Magellan Complete Care staff utilizes national evidence based guidelines (EBG) as a basis for assessment, evaluation, quality management and improvement, identification of care gaps, enrollee and provider education, key interventions and outcomes measures. Staff has additional resources available to

http://www.magellancompletecareoffl.com/

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them including: • Magellan’s proprietary, evidence based integrated care guidelines • Milliman Chronic Care Guidelines • Magellan’s proprietary behavioral health medical necessity guidelines • MCG medical necessity guidelines are currently in use. • Healthwise and Milliman Chronic Care Guidelines for health education materials in English

and Spanish • The American Society of Addiction Medicine (ASAM) Criteria

Case management activities including Care Coordination, disease management, and complex case management as well as interaction with providers regarding treatment plans take into account the enrollee’s cognitive and behavioral health status and are customized to best meet the enrollees’ needs. Staff members who perform complex case management are able to access EBG through the TruCare system and its related resources. Assessment tools used in the complex case management program are evidence-based.

Examples of Magellan Complete Care guidelines include:

• Asthma – National Heart, Lung, and Blood Institute (NHLBI) guidelines • Diabetes – American Diabetes Association (ADA) guidelines • Congestive Heart Failure – American Heart Association/American College of Cardiology

(AHA/ACC) guideline • Hypertension – National Institutes of Health (NIH) Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) • HIV/AIDS – NIH guidelines • Chronic Obstructive Pulmonary Disease (COPD) – the Global Initiative for Chronic

Obstructive Lung Disease (GOLD) guidelines • Immunizations – the Advisory Committee on Immunization Practices (ACIP)

recommendations • Preventive care – United States Preventive Services Task Force (USPSTF)

Examples of adopted behavioral health guidelines include the following Clinical Practice Guidelines from the American Psychiatric Association (APA):

• Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post- Traumatic Stress Disorder

• Practice Guideline for the Treatment of Patients with Major Depressive Disorder • Practice Guideline for the Treatment of Patients with Bipolar Disorder • Practice Guideline for the Treatment of Patients with Eating Disorders • Practice Guideline for the Treatment of Patients with Panic Disorder • Practice Guideline for the Treatment of Patients with Schizophrenia • Practice Guideline for the Management of Children with Autism Spectrum Disorders

Health Information Systems for Complex Case Management

MCC utilizes the TruCare case management documentation system to coordinate care for all enrollees, including those who have the most complex health needs. TruCare is the MCC application providing clinical systems support for utilization management, case management, health promotion, disease management, and Care Coordination tasks. TruCare integrates with our claims processing and provider data applications to enable Health Services staff to assess enrollee needs, complete Care Coordination

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plans, and authorize services. The system allows contracted Integrated Health Home (IHH) providers access to their patients’ Care Coordination plan if permitted by the enrollee.

TruCare supports the Care Coordination/case management plan and facilitates communication among health team members. The system stores and displays contact information for the enrollee’s Care Coordination Team and providers. It records and stores the Care Coordination plans (short and long term/prioritized goals, interventions, and progress on those interventions). In all instances, TruCare tracks the staff member’s identity and the date and time of his/her actions on the enrollees’ behalf.

System support for complex case management operates seamlessly within TruCare, establishing a single platform for MCC staff across the whole continuum of care and encompassing all care settings. The system allows the care team access to evidence-based guidelines, provides them with suggested interventions and prompts them to assure task or action completion. For example, staff receives automated prompts for follow-up with their enrollees through:

• Care Coordination/case management Plan notification for- review of the goal and intervention

when due • TruCare reminds a team enrollee when follow-up is required based upon the diagnosis and

completed plan of action

All of this data is contained in a data warehouse for ongoing monitoring and analysis of program activity, staff and enrollee engagement, and outcomes.

TruCare effectively tracks enrollee programs and case artifacts in one place. The system allows the complex case manager to assess an enrollee’s health status by simultaneously viewing co-morbidities within the template-based, configurable care planning tool. This allows users to quickly individualize care plans for enrollee-specific conditions, while driving program consistency. TruCare’s task management system shows required tasks in order of priority through a single shared platform showing user and enrollee information as well as input of other care team members’ tasks, which automatically populate. The system proactively identifies upcoming as well as missed tasks to expedite appropriate interventions. Through a rules-based feature, MCC is able to find and outreach to sub-populations of enrollees with certain diagnoses, services, or combinations of factors such as age and recency of preventive care services. Once identified, the system supports interventions for the population through tasking, correspondence, or other processes.

Element F– Case Management Process

The CCM procedures address the following: • Initial assessment of enrollees' health status, including condition-specific issues. • Documentation of clinical history, including medications. • Initial assessment of the activities of daily living. • Initial assessment of mental health status, including cognitive functions. • Initial assessment of psychosocial issues • Initial assessment of life-planning activities. • Evaluation of cultural and linguistic needs, preferences or limitations. • Evaluation of visual and hearing needs, preferences or limitations. • Evaluation of caregiver resources and involvement. • Evaluation of available benefits within the organization and from community resources. • Development of an individualized case management plan, including prioritized goals, that

considers the enrollee’s and caregivers' goals, preferences and desired level of involvement in the

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case management plan. • Identification of barriers to meeting goals or complying with the plan. • Facilitation of enrollee referrals to resources and follow-up processes to determine whether

enrollees act on referrals. • Development of a schedule for follow-up and communication with enrollees. • Development and communication of enrollee self-management plans. • A process to assess progress against case management plans for enrollees.

Multidisciplinary Team Roles

Magellan Complete Care designates care coordination teams to carry out procedures required in care coordination, complex case management, and other related care management programs. The care coordination team includes the enrollee or designated representative, the primary behavioral and medical treating providers, a Health Guide, and if indicated by the enrollee’s circumstances, an Integrated Care Case Manager. A clinical pharmacist, peer support specialist, and medical directors (with physical and behavioral health expertise) are also available to the Care Coordination Teams at all times. The CareLine is available to enrollees 24 hours a day / 7 days a week and is staffed by Integrated Care Case Managers. Enrollees can call the CareLine anytime for assistance as a back-up afterhours, on weekends or if they are unable to otherwise reach their assigned Case Manager including when their assigned Case Manager is on paid time off. All enrollees have access to some level of the care coordination services and team engagement. Through the use of stratification algorithms, the frequency of meetings and type of participants on the team vary, addressing the specific needs of the enrollee, and depending on whether the enrollee receives care coordination and complex case management services through a patient-centered health home or the more typical health plan system. Care is coordinated through all levels of practitioner care including primary care and specialists. Care coordination teams for individuals assigned to a health home are co-led by the health home and by a Magellan Complete Care Health Services staff member. Designated Magellan Complete Care staff lead care coordination teams for individuals receiving services outside of a health home.

The Health Guide is the enrollee’s advocate and helps the enrollee navigate through the delivery system. The Health Guide is community-based, where they can help the enrollee make and keep appointments with behavioral and physical health providers, and provide follow-up after appointments and coordinate with community agencies and other resources, as needed. The Health Guide assists the ICCM in ensuring that the care coordination plan is implemented as designed.

The Primary Behavioral Health Provider is responsible for overseeing the delivery and quality of the behavioral health services that the enrollee receives. The Primary Medical Provider oversees the medical services that the enrollee receives to ensure they are medically appropriate and coordinated. Other Provider Specialists may participate on the care coordination Team when the enrollee has a complex condition that requires specialist input and consultation.

As described earlier, through the Integrated Health Neighborhood approach, MCC’s Health Services staff coordinates with service providers and community organizations to meet the needs of the enrollee. These may include, but are not limited to, health care providers, behavioral health providers, Florida Assertive Community Teams, Managing Entities, Department of Children and Families, and homeless organizations/coalitions. The goal is to link enrollees with the appropriate service providers so that the providers can address the ongoing needs of the enrollees. Once linkage is made and the enrollee is engaged with the provider, MCC’s care coordination staff monitors enrollee progress through periodic

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contact with the enrollee and provider; duplication of services is avoided as much as possible. An example of one of MCC’s community integration programs is our Integrated Behavioral Health Pilot Program with Jackson Health System which was launched in February of 2017 in region 11. This pilot program is vertically integrated with MCC’s CCM program.

MCC also coordinates with other managed care/health plans on shared enrollees. This most often includes Long Term Care plans and Medicare plans. Health Services staff identifies enrollees who have long term care benefits and/or Medicare benefits and shares clinical information, when appropriate, to ensure the enrollee’s needs are accounted for and that there is no duplication of service between the plans. Protocols for Care Coordination

• Care coordination begins with the assessment of the enrollee’s level of functioning across many

areas including medical, behavioral, social, and environmental needs, including where the enrollee is receiving services.

• If unmet needs are identified, the care coordination team works in collaboration with the service providers and community resources to address those needs. This may include assisting the enrollee with referrals to providers, coordinating with providers to address unmet needs and adjust the treatment plan and/or service plan to account for the identified unmet needs.

• The care coordination team monitors the progress of the enrollee through periodic contact with the enrollee and service providers.

• If new problems are identified, or if an enrollee decompensates in area of functioning, Health Services coordinates care with the service providers and community resources to plan care accordingly.

Depending on the enrollee’s needs, the care coordination team members may include:

The Peer Support Specialist - a Certified Peer Support Specialist who is trained in applying resiliency and recovery principles and tools such as wellness recovery action plans, a wrap-around process, family and person-driven care, and systems of care that use these skills to provide emotional support and to inspire hope for the future. They model and assist enrollees in making lifestyle improvements and the self-management of chronic conditions. Peer support specialists provide additional outreach to individuals who require assistance to obtain access to and engage in needed services. The Pharmacist - participates as needed to review the medications the enrollee receives and in collaboration with the prescribing physicians on the team, is responsible for identifying potential over or under utilization, potential drug disease interactions, and optimal therapeutic regimens. The Pharmacist consults on complex cases where there is risk to the enrollee due to potential drug interactions between drugs for chronic medical conditions and psychotropic medications. The pharmacist will also take advantage of the sophisticated analysis of claims data to identify gaps or potential concerns.

The Integrated Care Case Manager - either an RN or a masters-prepared mental health or social work professional, is engaged for all high risk enrollees including the sub-population identified to receive complex case management. The case manager is responsible for developing the care coordination plan consistent with the enrollee’s health care needs and goals. The case manager monitors and intervenes for enrollees with complex situations and ensures implementation of the care plan. The case manager is actively involved at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the enrollee’s Health Guide to ensure care plan communication

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between all providers and enrollees.

The Care Worker - a non-clinical staff member, is responsible for supporting the care coordination teams. Activities may include, but are not limited to, mailing of letters/educational materials, obtaining authorizations for disclosure of protective health information, assisting with referrals, scheduling appointment, scheduling case conference meetings and assisting with other basic Care Coordination activities.

Enhanced Care Coordination processes and staffing requirements apply for medically complex and medically fragile enrollees under the age of 21 who are receiving services in a skilled nursing facility or who are receiving private duty nursing services in their family home or other community based setting.

Specialized complex case management also applies for individuals transitioning to or from long term care program services. These processes are described in policies and procedures.

Care Conference/Case Review and Interdisciplinary Care Coordination Team Conference

Formal Care Conference/Case Review meetings are held each day as an integral part of MCC’s holistic and integrated approach to deliver case management services to those individuals with complex behavioral and physical health care needs. Reviews are focused on new facility enrollee admissions or those enrollees who experience a significant event, safety risk, potential quality of care variance, or a complex physical and/or behavioral health situation identified as requiring intensive review and follow up. Additionally, the Health Services Team members including both Behavioral and Physical Health Physicians and Utilization Management professionals offer input informally and ad hoc throughout the day to assist the case management team in successfully coordinating services to a complex enrollee population. The medical team contributed to the creation of the Care Conference/Case Review approach and guidelines included in this document.

While the complex enrollees require an increased frequency of formal and ad hoc case reviews, the non complex enrollee case reviews and Care Coordination activities are carried out by the assigned care coordinator based on ongoing enrollee needs. Care transitions of any type are reviewed and discussed ongoing between the Care Coordination and Utilization Management teams. Our Care Transitions program incorporates the work of the National Transitions of Care Coalition and Eric Coleman’s Care Transitions Program®. www.ntocc.org; www.caretransitions.org

Goals of the Care Conference/Case Review Presentation

• Manage the integrated behavioral and physical care approach effectively and efficiently by

sharing information with the team that is responsible for the care and service coordination of the enrollee

• Obtain advice, guidance and insight of subject matter experts to improve the care planning process ensuring optimal care and safety of the enrollee

• Create an understanding of the unique and complex needs of the integrated population which • may or may not respond to traditional case management approaches • Share best practice and successful interventions that can be used for other enrollees • Enhance and develop approaches and tools that can be used systematically for the program • Share problems or poor outcomes to identify what should be done differently in the future –

focus on “lessons learned” and “missed opportunities”

http://www.ntocc.org/

http://www.caretransitions.org/

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• Discuss best practice care transition approaches, including look back periods as to what may have precipitated the transition along with contingency plan development

• Share information that can be used to demonstrate how the program works to external audiences such as regulators or other clients

• Identify and report potential quality of care variances

Interdisciplinary Care Coordination Team (ICCT) Meeting The Integrated Care Case Manager and the care coordination team serve as a means for achieving client wellness and autonomy through advocacy, communication, education, and identification of service resources and service facilitation. In addition to the care conference/case review meetings, MCC conducts ICCT meetings for complex enrollees. The ICCT attendees include: MCC Health Services and care coordination team members, PCP (treating), Psychiatrist (treating), Specialist (treating), Enrollee/or Caregiver. Meetings are scheduled at least two weeks in advance and are 30-60 minutes in duration. The Integrated Care Case Manager assigned to the enrollee is responsible for inviting all ICCT participants and completing the required consent and authorization forms for all participants. Activities of the ICCT meetings are documented and maintained within the TruCare system. Follow up ICCT activities include: Implement ICCT recommendations, document ICCT meeting in TruCare’s structure note type: Care Conference/Case Review, monitor and measure outcomes to measure the effectiveness, and distribute updated care plan to ICCT members. Assessment and Care Planning

Both the HRA and ongoing clinical assessments gather in-depth clinical information about enrollees that can be used to identify and prioritize both short and longer-term care coordination needs. The assessment addresses physical and behavioral health conditions, pregnancy and pediatric specific domains, long term support service needs, assignment to a health home or chronic care home with a special emphasis on identifying an enrollee’s need for resources, referrals, preventive health programs and community supports. An example of some of the key domains included within the Initial Clinical Assessment are as follows:

• Physical, psychosocial, cognitive and functional needs; • Comorbidities; • Pregnancy/Prenatal/Perinatal/Postpartum; • Cultural Needs Assessment; • Ability to perform ADLs; • Primary Care Provider and Specialists • Medication adherence; • Behavioral health and substance abuse screening; • Clinical history, including condition specific issues and medications; • Mental health history; • Long term support service needs and what services currently receiving; • Assessment of life planning self directed care activities; • Evaluate caregiver resources and social supports; • Utilization history; • Fragility;

Magellan Complete Care endeavors to perform a baseline assessment of each enrollee, as described

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earlier. The baseline assessment includes the annual Health Risk Assessment. Ongoing clinical assessments are conducted based on overall enrollee needs.

The reassessment process reviews progress towards goals, efficacy of the current care plan and provides data to compare against the information obtained in the initial HRA and comprehensive clinical assessment, specifically looking for changes in the enrollee’s:

• Functional status; • Caretaker status; • Skilled Care Needs; • Cognitive Status; or • Behavioral Health status

The reassessment information is compared to the enrollee’s baseline data and provides updated information for development or progress of the enrollee centered plan of care. The reassessment identifies and updates the current status of the enrollee and progress made from baseline assessments obtained and includes assessment in the following domains:

• Fragility; • Physical, psychosocial, cognitive and functional needs; • Documentation of the enrollee ‘s recent clinical history; • Ability to perform ADLs; • Evaluation of caregiver resources and social supports; • Housing/safety risk assessment; • Behavioral health history, including substance abuse; • Medication history and adherence; • Assessment of life planning and self directed care activities; • Assessment of vocational/educational activities/goals; • Lifestyle assessment; and • Nutrition assessment

Using the data sources described above, new and existing enrollees can be identified as potentially high risk, candidates for disease management or other care coordination programs. In this case, additional assessment is performed by staff members with appropriate training and credentials.

For enrollees identified with the highest complexity level, the Integrated Care Case Manager reaches out to the enrollee and/or family and supports in order to conduct a complex case management needs assessment. This provides a snapshot of the enrollees’ health status, condition-specific issues and history, medications, ability to perform activities of daily living, cognition and mental health status, life planning activities, cultural and linguistic needs or preferences, and caregiver resources and involvement. The Integrated Care Case Manager also reviews available benefits within the organization and from community resources.

Based on the risk factors identified in the HRA, an enrollee may receive specialized assessments to address various problems, including but not limited to, substance abuse, depression, HIV, pregnancy, and Disease Management conditions. Based on these assessments and other information, a goal-oriented and person-centered care coordination/care treatment plan is developed, with individualized and prioritized short and long term goals and interventions to achieve those goals. The care plan is developed with input from the enrollee. Interventions are tailored to the specific needs of the individual and take into account his/her risk level. Every effort is made to include the enrollee’s treatment preferences including language, culture, providers, and location when developing the care plan and in the coordination of care on behalf of the

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enrollee. Care Coordination plans are created in the clinical system where they are available for input and collaboration of the Care Coordination Team. In addition to promoting treatment plan adherence and coordination among treating providers, the Care Coordination plan promotes health and wellness activities including preventive care and healthy lifestyles. The following are typical topics for care coordination/care plan goals and interventions:

• Promote Coordination among providers (i.e. behavioral health and physical health) • Schedule appointments for follow up care • Monitor adherence with scheduled appointments • Abnormal or missing lab results • Conduct shared treatment planning session • Health education to individuals and family enrollees about managing their ongoing medical

conditions • Work with enrollee to identify personal health targets related to condition and steps to meet

them. • Close Gaps in Care • Discuss with treating provider • Refer to a Disease Management (DM) Wellness Specialist • Provide Integrated Health Services • Set up weekly appointments to facilitate a relationship with the provider team • Self-management support and development of self-management plans and/or relapse prevention

plans • Engage enrollee in condition education • Practice using the symptom response plan • Support Transitions in Care • Assist in arranging transportation for follow-up appointments • Attain personal health goals • Reinforce proper coping skills when dealing with stressful situations • Self direction and skill development in the area of independent administering of medication and

medication adherence • Arrange in-home support for medication management • Increase overall support systems

In addition to creating, prioritizing and managing goals and interventions, the care coordination/care plan includes the following features:

• Contact information for individuals involved in the care and support of the enrollee • Summary information section to record risk assessment, treatment plan, Care Coordination

and strengths assessment • Ability to attach documents as indicated • Provides the ability to share the Care Coordination plan with other Magellan Complete Care

staff, and with behavioral health and medical providers with appropriate permissions to view the enrollee information.

When creating the care plan, the Integrated Care Case Manager identifies the date when the prioritized goals should be achieved. He or she continues to update the care plan throughout the duration of the enrollees’ engagement with complex case management but minimally, care plans are updated at least every 6 months or when significant changes occur in the enrollee’s condition. Care coordination supervisors review a sample of enrollee files to assure the care plans meet the standards and discuss findings in individual supervision meetings.

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The Integrated Care Case Manager monitors the enrollee’s success in engaging in treatment and identifies barriers or clinical issues that may impact the individual’s health status or progress in achieving the goals and outcomes outlined in the care plan. The case manager and other members of the Care Coordination Team communicate with an enrollee based upon their preference including telephonic or face to face. The Care Coordination Team will also engage the enrollee’s providers, assuring effective communication and ‘same page’ care when multiple specialty providers and disciplines are involved, and assuring enrollee/provider communication is occurring as needed.

The Integrated Care Case Manager is actively involved with the enrollee at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the enrollee’s Health Guide to ensure care plan communication between all providers and enrollees of the Care Coordination Team. The Health Guide helps the enrollee make and keep appointments with behavioral and physical health providers, provides follow-up after appointments and coordinates with community agencies and other resources. Others on the team provide their specialized roles, as needed. For example, the Peer Specialist models and assists enrollees in making lifestyle improvement and self management of ongoing medical conditions through treatment and medication adherence.

Behavioral Health Philosophy and Approach MCC of Florida believes that the most effective and appropriate behavioral health services are best delivered as part of a fully integrated recovery-oriented system that welcomes and engages members and participants at all points in their personal recovery journey - one that recognizes and builds upon individual strengths, needs and preferences of the member. Helping people reach their goals for a better life is our primary focus. We believe that all people can recover from trauma, tragedy, or other stresses. We help people manage their long-term behavioral and chronic conditions and believe that people can and do get better and are able to build a life filled with meaning and purpose. MCC of Florida’s model of care is built on the understanding that our member’s ability to get healthy, stay healthy, and stabilize chronic conditions is intrinsically tied to multiple sectors outside of the health and wellness spectrum. The social determinants, resources, and conditions within a member’s immediate environment, (e.g. supportive housing, availability of healthy food choices, presence of racism and discrimination, public safety issues, and available transportation options), can impede or support their ability to achieve their health and wellness goals. Our behavioral health model takes into consideration these social determinants as we determine member needs and the continuum of services most likely to address those needs. Our approach for delivering behavioral health services is structured to assure that improved behavioral health is achieved by making an impact, one member at a time, through highly individualized, community-based approaches to healthcare delivery, care coordination, and self-direction. Our model of care improves the behavioral health status of Floridians by engaging and empowering members, partnering with providers, and integrating community resources and non-traditional services into local health systems. Early identification of high-risk members through mental health and substance use screening tools is critical in order to get members the care they need at the right time, in the right place and in the right amount. This leads to prevention and/or early intervention and promotes community tenure, which results in improved quality of life, satisfaction for our members, and cost effectiveness. We use a person-centered treatment planning approach that places the member and family in the center

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of the planning process and involves all stakeholders in the member’s care. This approach promotes communication, integration, and coordination of care and services, reducing inefficiency and duplication of services. We deliver behavioral health services through a large established credentialed and contracted network – that has the capability to provide services across the State and across the continuum of care. MCC of Florida uses Milliman Care Guidelines (MCG) and ASAM criteria in conjunction with the Department’s policies to make medical necessity determinations. MCC’s guidelines are consistent with Federal, State, and the Department’s requirements. MCC’s medical necessity criteria are not more restrictive than the State’s criteria and its’ coverage rules and authorization practices comply with the Mental Health Parity and Addiction Equity Act (MHPAEA). MCC coverage rules for behavioral health treatment services are also compliant with Federal EPSDT coverage requirements for Members under the age of 21. Care Transitions and Discharge Planning

The MCC Care Transitions and Emergency Department Follow Up Program activities are integrated within each area/level of the care coordination program. As mentioned earlier, the MCC care transitions and emergency department follow up activities are based on a blend of key components of the National Transitions of Care Coalition and Eric Coleman Care Transitions Program®. MCC also works with existing community transition programs to further ensure a safe transition plan for each enrollee. Outreach and enrollment activities are based on enrollee need.

CARE TRANSITIONS

PROGRAM Care

Care Coordination

Team Members

Accompany

Discharge Planning /post

Discharge Follow Up

(Care Team

Anticipatory Transitions

Early Problem Identification/ Case Review

Behavioral

and Physical Health Home

ER Follow Up

CareLine

Enrollees to Office Visits -

Close Care Gaps

Members On Site in

Hospital/ER)

GOALS OF THE PROGRAM: Facilitate Anticipatory Management of Enrollees' Care Increase Enrollee Adherence Facilitate Self Care Decrease Unnecessary ER Use Decrease Unnecessary Admissions/Readmissions Improve Quality of Life and Enrollee Satisfaction Decrease Unnecessary Cost of Care Improve Gap in Care Closure

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The Care Transitions Program, including the on site discharge planning visits, offer discharge planning between care episodes and proactively focus on key activities to prevent avoidable hospital admissions/readmissions, or emergency department (ED) visits. The program promotes physical and behavioral health comprehensive care transition management both proactively while an enrollee is enrolled in a care management program, and when an emergency department visit or hospital admission/readmission occurs. MCC case managers and health guides understand how coordinated health care improves the behavioral, social, and medical care of the membership. The case managers and health guides coordinate care for the enrollee by focusing efforts on proactive care management interventions to prevent the unavoidable including:

• Setting enrollee-specific, prioritized goals that promote coordinated care; • Providing enrollees and families one point of contact; • Making and keeping specific tasks/appointments/calls and follow up items with enrollees; • Reducing enrollee emergency department visits, hospital admissions, and readmissions; • Coordinating care within and across treatment settings; • Creating a process through which health care providers can communicate with one another about

the enrollee’s care; • Making enrollee preferences known and accessible to all health care providers; • Contact all enrollees on discharge from an inpatient admission ensuring a coordinated,

comprehensive transition plan; Promote increased compliance with the enrollee’s discharge plan and individualized care treatment plan – establish contingency plans as needed;

• Facilitate enrollee self-management capabilities; • Close gaps in care; • Establish a health and medical home if one does not exist.

The case manager and health guide maintain the responsibility and continue to be the primary advocate in ensuring the enrollee’s well being across multiple care settings. Whenever possible, the case manager communicates with all relevant medical and behavioral health care entities, including hospital emergency department), inpatient, outpatient settings (residential services, day treatment programs, case management, therapy, medication management) as well as specialized nursing home facilities from the time of initial involvement through the discharge period. The case manager ensures that the highest quality of health care is delivered to the enrollee in each of the health settings. The initial evaluation for discharge planning begins at the time of notification of ED visit and/or inpatient admission and continues along the entire continuum of care. The case manager reviews complex cases within the case review conferences which are held daily. The case review session allows for a Medical Director led interdisciplinary team of MCC staff to review complex cases to ensure that the highest level of quality care and follow up is being provided for the enrollee.

Any post discharge requirement for durable medical equipment (DME), home health, community outreach, community agencies, medication assistance/reconciliation, and community mental health services are identified as early as possible before or during an enrollee inpatient stay to ensure availability for a timely discharge. A comprehensive discharge plan includes, but is not limited to, the following:

• Assessment of needs – upon hospital admission • Assessment of needs – when notified that the enrollee is in and is discharged from the ED • Plan development – (inpatient or ED) determine the behavioral and medical health care discharge

needs; plan to meet those needs; confer with Primary Care Provider (PCP)/Specialist

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• Plan implementation – (inpatient or ED) • Evaluation of effectiveness – (inpatient or ED) • Provision of proactive ongoing or cyclic care • Follow up care after discharge • Formal review of complex cases at the daily case conference sessions

To further enhance and improve the MCC enrollees’ facility transition of care experience, a key component of the care transitions program is the discharge planning program. The Discharge Planning Program is designed to safely transition enrollees from an inpatient admission in an acute care, skilled nursing facility, or ED back to home or community setting. The Discharge Planning Program is unique in that it targets enrollees while in an inpatient or ED setting; it augments existing care management activities to ensure a smoother transition for enrollees from the hospital to home. The Discharge Planning Program actively monitors inpatient admissions and has established relationships with inpatient and community based setting staff. The goals of the Discharge Planning Program are focused on decreasing ED utilization, decreasing hospital admissions/readmissions, increasing compliance with the provider’s discharge plan, increasing use of appropriate pharmaceutical choices/combinations, increasing appropriate community referrals, and increasing enrollee satisfaction and health outcomes. The Discharge Planning Program enhances the Care Coordination program as it formally bridges and aligns the inpatient on site facility or ED activities with ongoing care management team interventions. The Discharge Planning Program targets specific enrollee populations and builds upon the close relationship between the Discharge planning staff and Care Coordination team. The care coordination team has access to current and best practice tools, including, the National Transitions of Care Coalition, Eric Coleman’s Care Transitions Program, MCC Case Review/Care Conference Guidelines and Approach and Medicare.gov. Additional Care Coordination Program Considerations & Innovation

Complex Condition Specific Programs and Subject Matter Experts Throughout 2016 and into 2017, MCC of Florida has developed targeted and focused programs specifically tailored to meet the needs of members presenting with complex conditions. Subject matter experts and teams have been assigned to membership with these specific conditions and member needs. An example of these focused programs include:

• Sickle Cell Disease • Depressive Disorder • Schizophrenia • Transplants • High Risk Pregnancy • High Risk Pediatric Programs • HIV/AIDS • Diabetes

Informing Enrollees and Providers

When eligible enrollees choose MCC as their specialty managed health plan, they are provided with educational materials including an enrollee handbook, newsletters, and website information where they

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are invited to learn about MCC benefits, health, wellness, Care Coordination, and case management programs. Enrollees can access any of the MCC programs by calling enrollee services or the CareLine program after hours.

The CareLine is available to enrollees 24 hours a day/7 days a week and is staffed by Licensed Clinicians (RNs and Mental Health Professionals). Enrollees can call the care line anytime for assistance for symptom education, provider referrals, general health and wellness related questions, or if they are experiencing a crisis or emergency of any kind. The taking the call has access to a host of resources to assist the enrollee in obtaining the necessary information or in getting to the right level of care for their symptom management.

Enrollee educational and outreach initiatives are conducted using culturally and physically sensitive techniques, including methods to provide education to enrollees who have visual impairments (such as audio educational initiatives), hearing impairments (such as using TTY phone numbers), and low literacy levels.

The MCC provider network includes providers who specialize in the management of enrollees who have serious mental and physical health illnesses. MCC educates current and new providers through provider newsletters, new provider orientation, and through the provider manual. MCC provider relations staff members educate providers on new products utilizing multiple communication venues.

Enrollees are informed about their options to access network providers by reviewing the provider directory. Enrollees can change their assigned provider by calling member services and if an enrollee requests a specialist to act as their primary care provider, MCC will work with the enrollee and providers to review this option and will honor the request if possible. If the enrollee’s provider is not in network, MCC will work with the provider to become an in network provider if possible. MCC will also work with enrollees to find in network providers whenever possible.

Continuity of Care Guidelines

Magellan Complete Care has developed Continuity of Care Guidelines. The goal of these guidelines is to ensure a seamless continuity of care experience for any enrollee who is transferring to or from a different health plan or payer which often also includes changing health/service providers.

When Magellan Complete Care receives a newly enrolled individual or when an enrollee chooses a different health plan or payer, Magellan Complete Care ensures that the enrollee’s care and services continue without disruption. Magellan realizes that enrollees have the right to continue to receive needed services, even if they are no longer able to receive them from the same payer or health/service provider. During any transition, Magellan Complete care staff members review medical supply, equipment, and medication providers to ensure continuity of provision, payment, and quality at all times.

When Magellan Complete Care is notified of a newly enrolled enrollee or an enrollee who is disenrolling from the health plan, at minimum, the following is carried out:

• Obtain appropriate consent from the enrollee to obtain and share demographic and healthcare information.

• Collaborate with the enrollee, the health/service provider, and the receiving or sending health plan to obtain/provide enrollee information related to the respective program assessments and service plan/care plan information.

• Request/share the most current assessment and service plan/care plan with documentation of same in the TruCare documentation system.

• Assist enrollees in finding in-network health and service providers whenever possible.

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• Assist Nursing Facility confined enrollees in exploring the possibility of returning to the community through formal collaboration with Magellan Complete Care transition subject matter experts.

• Documentation of continuity of care assessments, health risk assessments, and service plans/care plans and/or other information is scanned/entered into the TruCare clinical documentation system.

Healthy Behaviors Programs

MCC offers its enrollees three health behaviors programs: weight management, substance abuse, and smoking cessation. All three programs have their own program description outlining the program, their requirements, and how the program incentives are structured. Monthly metrics on each of the programs are monitored by the Health Services Committee. Refer to the individual program descriptions for more information.

Resource Guide

MCC identifies community, social, and recovery services that are available at the county level and has developed a resource guide which is available to key stakeholders. Social Workers on staff are available to assist in the identification of local community resources to aid the enrollee. Care Coordination staff share information regarding local community agencies, or faith based organizations that may be of assistance with the enrollee and/or provider(s), when indicated. MCC has developed a case management tool kit which includes fundamental care coordination and case management information and resources to effectively carry out critical case management activities. The tool kit includes evidence-based clinical guidelines for both professional and enrollee use. Quality Improvement, HEDIS, and Clinical Performance Measurement

MCC utilizes an enterprise wide and fully integrated approach to carrying out key quality improvement, HEDIS, and clinical performance measure activities. The health services team collaborates with the quality team to ensure that the quality improvement and HEDIS initiatives are fully integrated within the clinical and enrollee facing programs. MCC employees are educated on targeted quality, HEDIS, and quality measures. Current and new initiatives are discussed at the cross functional oversight and operational meetings to determine which key initiatives will be the focus for improving the key measures. Outcome measures are determined by the results of the HEDIS and state specific performance results. The quality, HEDIS, and performance improvement strategy utilizes a multifaceted approach incorporating clinical, data, and provider based efforts. Enrollee facing staff members carry out HEDIS and quality measure initiative calls encouraging enrollees to obtain care and preventive services they need to improve overall health and to establish a medical/behavioral health home. Confidentiality

MCC is committed to maintaining the highest level of confidentiality of the enrollee’s medical and behavioral health information. MCC has written policies and procedures regarding protected health information and authorization to use and disclose information. MCC employees are trained on the confidentiality policies during new employee orientation and on an annual basis. MCC, not only ensures compliance with HIPAA, but also ensures compliance with 42 CFR part 2, F.S. 394 and 397 which are more

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stringent in protecting mental health and substance abuse information. Additionally, all authorization to disclose (AUD) forms, which contain all elements as required by law, are reviewed by MCC’s compliance team prior to staff releasing protected health information. Each approved AUD form is attached to the enrollee’s record in the case management system and are updated at least annually. Program Evaluation

Monitoring and measuring the effectiveness of the MCC Care Coordination Program occurs through ongoing review of enrollee health outcomes, performance measure results, regulatory and accrediting body benchmark results, and utilization trend results. HEDIS and other pertinent quality outcome measurement results are monitored on an ongoing basis. Various enrollee surveys are conducted throughout the year with ongoing review and measurement of survey results. Clinical monitoring and auditing is carried out, including inter rater reliability to ensure compliance with the key components of the case management process. The Care Coordination program is reviewed and updated, at minimum annually, under the direction of the VP, Health Services. All aspects of the program including process, documentation, etc., are reviewed within the auspices of the clinical monitoring program. The program reports its activities and is reviewed by the quality improvement committee. This committee provides physician and other key expert oversight and input into the program. The Care Coordination Program metrics are incorporated into the quality improvement work plan which is created annually.

Care Coordination Goals for 2017

1. CCM Enrollee Satisfaction: 85% (or greater) of enrollees in the complex case management program will report satisfaction with the program.

2. Enrollee engagement: 95% of enrollees successfully engaged and identified as complex case management have a clinical assessment and care plan completed within 30 days of CCM program enrollment. If unable to contact, ICCM will have made 3 contact attempts in 14 days of opening the program.

3. 30 Day Readmission Rate: Achieve or exceed threshold readmission rates of 25% (or greater) for PH readmissions and 30% (or greater) for BH readmissions.

4. Integration: Care plans for enrollees in complex case management will have at least 1 BH focused goal and 1 PH focused goal.

5. Care Transitions: enrollees discharging from a BH inpatient admission will achieve a 7 day follow up after hospitalization rate of 52.99% (or greater).

6. Collaborate with Quality department to exceed designated/agreed upon HEDIS measure performance targets.

Attachment 1

Risk Model MCCFL_v5.pdf

Documents

MMA SRC #10, Attachment 1: Care Coordination … 08/MAGELLAN...and information used by the TruCare clinical documentation system development team. The care coordination program incorporates