Cross System Care Coordination

Care Coordination

Importance of the role of care coordination and partnering across systems:

Medicare Advantage (MA) and Managed Care (MCO) plans are responsible to coordinate across systems of care just like Long Term Care (LTC) to help ensure timely and coordinated transitions of care (from institutions to community) and meet the needs of clients in the community.

How does care coordination benefit our mutual clients?

  • Increase our understanding of managed care services and supports
  • Increase Managed Care and Medicare Advantage plans understanding of our system and how they can support shared clients
  • Offer new thinking around ways to improve coordination and collaboration as community transition planning partners and ongoing care coordination partners.​

When and How to Engage System Partners  

How to reach out to coordinate with our cross systems partners. 

  •  HCA/AAAs can find the contact list of the MA health plans on the ALTSA Intranet 
  • Medicaid and Medicare Managed Care Coordination Contact List 
  • MA plans may find the HCS/AAA case manager listed in PRISM if the individual has LTSS authorized services. 
  • Area Agency on Aging (AAA) Statewide contact list 
  • Template Email templates- What should be included when reaching out to request care coordination. 
  • Need to escalate a client to staff with the AAA/HCS Case Manager? 
    • There are biweekly staffing meetings with each MCO established, for information on how to escalate a client to staff please reach out to: MCSCsupport@dshs.wa.gov 

Resources and Trainings

Resources

Stakeholder Resources

Trainings

Understanding Entities’ Roles

Individuals responsible for achieving successful transitions of care and care or case management should be well versed on the services available to clients/beneficiaries and how to access them. While we cannot all be experts in all the things, we can partner across the delivery systems to address gaps in care and achieve more efficient and cost-effective service delivery.

Area Agency on Aging (AAA):

  • Information and Assistance (no wrong door access to local community services and supports)
  • Case management of Medicaid LTC clients served in their home.
  •  Conduct ongoing functional assessments for LTC and service plans
  • Assist with transition to LTC services or settings
  • Case management for other programs like supportive housing, state funded family caregiver support programs, Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA)
  • Some AAAs have special programs like Health Homes or care transitions
  • Contract Medicaid LTC providers
  •  Other social support services (local expertise) e.g.:
    •  Transportation
    • Nutrition Services – congregate or home delivered meals
    • Family Care Giver Support
    • Information and Assistance
    • Environmental modifications

Home and Community Services (HCS)

  • Initial eligibility determination for referrals to the Medicaid LTC system.
  • Financial eligibility determination for some Medicaid clients
  • Conduct person centered initial and ongoing functional assessment and service plan
  • Residential and SNF case management
  • Assist with referrals as identified in the functional assessment
  • Assist with transitions of care from inpatient to community LTC and from different LTC settings.
  • Authorize Medicaid LTC services
  • Contract LTC residential settings and services

Medicare Advantage(MA) Dual Special Needs Plan (D SNP) Medicaid Managed Care (MCO) :

  • Responsible to conduct an Initial Health Risk Assessment and offer care management services if indicated.
  • Assist with transition planning and responsible to locate and assist with scheduling post discharge appointments with providers
  • Coordination with the BHSO (behavioral health plan) as appropriate
  • Reviews/approves authorization requests for Durable Medical Equipment (DME)
  • Timely Prior Authorizations for medically necessary care like SNF, Home Health or other care
  • Track in-patient stays and identify opportunities for early intervention, assist with transitions
  • Responsibility for Medicare-covered benefits and to coordinate Medicare benefits and services
  • Offer Supplemental Benefits (vary depending on the plan) could include:
    • Transportation
    •  PERS
    • Transitional Meals
    • Utilities, Over the Counter (vitamins, basic supplies), and Healthy Food Card

Medicare Advantage Plan Information

MA Plans can find a list of locations and general contact information for AAA and HCS Offices on the ALTSA resource webpage https://www.dshs.wa.gov/ALTSA/resources

Contacts