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Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities

Care Coordination

Minnesota Senior Health Options


David W. Walsh, M.H.A., Federal Program Manager, UCare Minnesota, St. Paul, MN.

The Minnesota Senior Health Options (MSHO) program integrates Medicaid and Medicare funds with Federal waivers and integrates acute and long-term care services including home and community-based services (HCBS).

MSHO's goals are to:

  • Reorganize the delivery system in order to support sound clinical incentives.
  • Enhance care coordination.
  • Reduce administrative complexity.
  • Provide a "seamless" point of access for consumers and providers; the program is also designed to control cost growth through incentives to use the lowest cost intervention appropriate to the need and to change utilization patterns.

UCare of Minnesota is one of three plans participating in MSHO. This Managed Care Organization (MCO) decided to participate in order to develop better care coordination for its members and to integrate across the acute and long-term care continuum.

UCare uses a primary care clinic-based system and contracts with other systems, such as EverCare, for care coordination and physician services for enrollees living in nursing facilities, counties for HCBS, and specialty care providers. This network has been formed into a series of care systems, each with unique features; UCare oversees the care system processes.

When asked about the incentive for care systems to meet MSHO's goals, particularly to use the lowest cost intervention appropriate to the need, Mr. Walsh replied that UCare holds quarterly meetings with each of the care systems to discuss such issues as part of the oversight function.

Mr. Walsh described care coordination as "the linchpin of MSHO's success." Upon enrollment, a member chooses a primary care clinic that is part of a care system. A care coordinator from that care system is then assigned to that member. Each member and his/her family has a care team: the care coordinator (who is primarily responsible for coordination), the primary care physician (PCP), a UCare liaison nurse, and a county or nursing facility representative. Teams meet on a situation basis. The success of the care team has thus far depended on the persistence of the care coordinator in reaching out to providers, especially physicians.

Most care coordinators are registered nurses (RNs) based in the clinics; a few work directly for the MCO. Care coordinators do not need prior authorizations for services from UCare but do need physician approval. Caseload varies from 75 to 150 members.

Care coordinators are responsible for:

  • In-home assessments (upon enrollment and every 6 months afterward, using a tool developed by the National Chronic Care Consortium).
  • Development of a care plan (with input from the beneficiary, the caregiver, and others on the care team).
  • Access and coordination of services (including through transitions).
  • Serving as the primary contact for members and their families.

This care coordination has resulted in the improved ability to care for the member in the most appropriate setting. For members residing in nursing homes, care coordinators focus on medical services; social services are handled by the nursing facility itself. For members in the community, care coordinators focus on both medical and social services.


National Chronic Care Consortium. Case management for the frail elderly: a literature review on selected topics. Bloomington (MN): Minnesota Department of Human Services, Minnesota Senior Health Options Project; 1997 Oct.

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