Complex Care Management Model Design

Carpenter J
Publication Year: 2016
Patient Need Addressed: Long-term services and supports
Population Focus: Complex care, Medicaid beneficiaries
Type of Literature: Grey

The steps to developing Complex Care Management Model Design for state Medicaid programs with a focus on one single point of entry. In this design, long term services and supports are provided in order for individuals to remain in the community.

Insights Results

Overview of presentation

  • This presentation provides an overview for managing long term support services for complex populations. Specifically, Medicaid focused complex care management involves the facilitation of Medicaid funded long term services and supports (LTSS) to enable individuals to remain in the community and avoid institutionalization
  • The presentation outlines 6 steps in model design: 1) Identify the population; 2) Determine the risk factors; 3) Identify interventions; 4) Develop plan of care; 5) Monitor outcomes; and 6) Continuous improvement
  • The goals of the program are to provide LTSS benefit coordination of Medicaid State Plan service, to simplify the prior authorization by establishing a single point of entry to Medicaid LTSS, and to ensure that Medicaid is the payer of the last resort for services by coordinating the LTSS needs of individuals with those available from other insurance or other payers
  • The specific program outlined in this presentation targets individuals who require continuous skilled nursing services and have certain categories of Medicaid insurance. The program includes a comprehensive in-person assessment completed by an RN, a plan of care of the patient, and ongoing monitoring of the utilization
  • A member survey highlights that 91% report overall satisfaction with care coordination in the program, 89% report the care coordination has resulted in having a positive impact on a person’s life, and 83% report it would be at least “somewhat difficult” to stay at home without this support
  • Estimated cost avoidance from program: FY 04-16 > $84M