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Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities
Pamela Coleman, M.B.A., Managed Care Director, Texas Department
of Human Services, Austin, TX.
Mary Matson, Supervisor, Long-term Care, Americaid Community Care,
Carolyn Tyler R.N., M.S., C.P.H.Q., Director of Medical Services, HMO
Blue STAR+PLUS, Houston, TX.
Delwin E. Beene, M.Ed., Program Manager, Access/University of Texas Medical Branch (UTMB) Health Care, Houston, TX.
Texas implemented the STAR+PLUS pilot January 1, 1998, in Harris
County (Houston area). The pilot operates under 1915(b) and (c) waivers
to integrate acute, behavioral, and long-term care. Participation is mandatory
for Supplemental Security Income (SSI) and related populations to obtain Medicaid services; Medicare
services may be obtained through the provider of choice.
The STAR+PLUS Managed Care Organizations (MCOs) have been encouraged to add 1915(c) waiver services and other services
not covered in the State Medicaid plan as value-added services, to attract
more members. Approximately 55 percent of members are eligible for Medicaid
only; the other 45 percent are dually eligible.
MCOs are required to contact members (at least by phone) within 30 days
of enrollment to do the initial risk assessments. The risk-assessment
tool was originally designed by the State for use by all MCOs. In addition,
the MCOs have tailored the tool and added new assessments to better meet
internal needs. More detailed assessments are done in-home with members
who are medically complex or at risk of accessing long-term care services.
The MCO is to assign or make available a care coordinator or coordination
team to each member.
Representatives from the three STAR+PLUS MCOs—Americaid, HMO Blue, and Access—discussed the implementation and operation of care
coordination functions. Discussion topics included:
Care Coordination Model:
- Americaid: Uses nurses and social workers as care coordinators
in assigning members to care coordination teams (which include PCPs).
Since the fall of 1999, Americaid has implemented a disease management
program for 11 diagnoses. This program includes measurable outcomes
for each member and for the program.
- HMO Blue: Has four teams of registered nurses (RNs), licensed vocational nurses (LVNs), licensed practical nurses (LPNs), and Masters of Social Work (MSWs)
serving as care coordinators. One team works by telephone, while three
field teams are set up with the technology to work from home. A special
member phone line is staffed by care coordination associates, who assist
care coordinators in followup and tracking, and act as liaisons between
the care coordinators, members, and providers. Care coordination is
service driven, rather than disease management driven.
- Access: All members are assigned to a care coordination
team according to their area of residence. There are four teams of adult
care coordinators and one team for pediatric members. Care coordinators
can be RNs, social workers, or other healthcare professions with extensive
experience in service coordination. Care coordinators use automated
care planning software to track and manage each member's care and services
Assignment of members to care coordinators:
- Americaid: Each member is assigned two coordinators—one
for medical needs and one for social needs—that work as a team.
- HMO Blue: Every member is assigned geographically by
residence (including specific nursing facilities) and according to service
- Access: Members are assigned first geographically by
residence and then by acuity.
Care coordinator interaction with primary care physicians (PCPs):
- Americaid: A care plan is created for each member, with
member sign off, dual and non-dual, and a copy is sent to the PCP. If
changes are made on the care plan, the PCP receives an updated copy.
If there are no interim changes, the PCP receives an annual care plan.
Whenever a non-dual member is hospitalized, the care coordinators contact
the PCP, or whenever there is a need.
- HMO Blue: The MCO's medical director assists in facilitating
- Access: Care coordinators work closely with PCPs to
develop plans of care and authorize services accordingly. For dually
eligible members, greater cooperation was obtained from their out-of-network
PCPs once they became familiar with the program.
Managing behavioral health benefits, particularly for people with
severe and persistent mental illness (Note: all three MCOs subcontract
with behavioral health vendors for these services):
- Americaid: A mental health specialist works closely
with both the care coordinators and the vendor.
- HMO Blue: A mental health liaison works closely with
the vendor; the liaison has a caseload of less than 30.
- Access: Maintains contact with the vendor via weekly
case conferences and regular telephonic review.
Meeting the needs of ethnic/racial minorities (Note: the State
requires cultural competency training in all STAR+PLUS MCOs):
- Americaid: Many care coordinators are multilingual.
- HMO Blue: Along with bilingual staff available to assist,
health educators from all MCOs meet periodically to ensure that training
and other materials are culturally appropriate.
- Access: Many care coordinators are bilingual. The MCOs
also use the AT&T language line and interpreters as necessary to
accommodate the members' linguistic needs.
Most difficult problems encountered:
- Americaid: Locating members after they have been discharged
from the hospital.
- HMO Blue: Developing support systems to allow individuals
to remain in their homes.
- Access: Establishing trust, especially among members
who are unused to working with a care coordinator.
STAR+PLUS. Senate Bill 1164 Report. Austin (TX): Texas Health and Human
Services Commission; 1999 Jan.