Cal MediConnect LTSS Best Practices Summary

One key focus of Cal MediConnect (CMC) – as well as the broader Coordinated Care Initiative (CCI) – is to better integrate long-term services and supports (LTSS) for Medicare and Medi-Cal beneficiaries. Several years into the program, evaluation findings indicate that, while CMC provides a valuable new pathway for serving dual eligible beneficiaries, more work can be done to connect members to LTSS services and to better integrate and coordinate those services with the more traditional medical benefits that health plans offer.

As one of several initiatives to address this ongoing challenge, during the spring of 2018, the CMC plans participated in a best practices process to examine their own internal operations and share learnings with each other. A summary of the best practices meetings was published in September 2018 and key findings from the best practices process include:

Identifying LTSS Needs

  • Plans have implemented the new standardized LTSS referral questions into their Health Risk Assessments (HRA). Having the CMC plan conduct the HRA seems to accelerate the LTSS referral process and improve care coordination between providers and the care team.
  • Beyond the HRA process, plans are connecting with providers and beneficiaries while they are hospitalized to assess LTSS needs. Plans have also developed systems to solicit referrals from internal departments as well as encourage external referrals from members, caregivers, skilled nursing facilities (SNFs), community-based organizations (CBOs), and other programs.

Connecting Members to Services

  • Plans are leveraging technology to support LTSS care coordination, including integrating the HRA into the electronic health record (EHR) so data is available across the care team. Care management software allows plans to use automatic reminders for care managers or providers to trigger follow-up.
  • For all types of referrals, plans are finding that it works best when care managers closely follow the referral process and when they work to build relationships with the LTSS providers.

Care Coordination Infrastructure:

  • How plans provide tailored care coordination to their members with LTSS varies; no model appeared as a single best practice and each model has benefits and limitations in serving members. General best practices include:
    • Have a general care manager (non-clinical) conduct the initial follow-up and then an LCSW or LTSS trained care manager provide follow-up on LTSS needs.
    • Integrate the care manager into the Interdisciplinary Care Team (ICT), and ensure referrals are reflected in the Individualized Care Plan (ICP).

Training and Education

  • Plans must train a wide variety of actors on LTSS services. Training should include who is eligible, how to identify LTSS needs (and recognize urgent needs), how to connect members with LTSS services, as well as resources in the community such as food, transportation, caregiver support, utility assistance, housing, etc.
  • In-service and orientation days at LTSS provider facilities can give staff the best understanding of how LTSS providers support their members.

Working with LTSS Partners

  • Several plans shared data with LTSS providers to help target and prevent unnecessary hospitalizations and emergency department visits.
  • Plans have worked to build close relationships between plan care managers and LTSS program care managers to improve care delivery and care coordination.

Download the full summary of the Cal MediConnect Best Practices Meeting.

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