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

Care Coordination



Pamela Coleman, M.B.A., Managed Care Director, Texas Department of Human Services, Austin, TX.

Mary Matson, Supervisor, Long-term Care, Americaid Community Care, Bellaire, TX.

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 provided.

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 level.
  • 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 these relationships.
  • 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.

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