caresource the managed care difference mission: the caresource heartbeat making a difference in the...
Post on 18-Dec-2015
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CareSource The Managed Care
Difference
Mission: The CareSource HeartbeatMaking a difference in the lives of underserved
people by improving their health care
Vision CareSource will be an innovative leader in the management of quality public sector health
care programs
CareSource Model Non-profit, mission driven Member Focused
• Enhanced benefits, no co-pays• CareSource 24 nurse triage service – excellent
customer satisfaction• Care Management continuum – member
centric care• Community based care management,
marketing, and provider relations programs• Regional Consumer Councils
Provider Focused• Physician enhanced reimbursement• Low hassle approach to medical management• Health Care Home Program• Provider portal tools to promote preventative
and wellness activities Best practice administrative efficiencies Technology investments
Why Managed Care? Quality• NCQA, URAC and best practice
compliant Accountability to Policymakers and
Taxpayers Budget Predictability Improved Access to Quality Health Care• Credentialing and provider
collaboratives Focus on Coordination of Care Cost Savings
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What Can Managed Care Do?
Challenges lead to opportunities in managing Medicaid members
• Addressing socioeconomic limitations
• Initiatives to improve access to quality, cost effective healthcare
• Management of multiple chronic and co-morbid disease states
• Integrated behavioral/physical health4
CareSource Focus
Quality provider network Integrated Care-• Mental Health, Substance Use
Disorders and Physical Health Medical Home-• Behavioral Health
Case Management Partnerships-• Access• Services-Evidenced Based Practices
Integrated Care
Mental Health, Substance Use Disorders and Physical Health• Improved Outcomes • Increased Efficiency• Increased Effectiveness• Increased Flexibility• Decreased Costs• Decreased Administrative Burden
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Medical Home
Behavioral Health• Patient Centered• Facilitates partnerships between
individual patients, personal physicians and patient’s family
• Bi-directional
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Behavioral Health Core Services
Evidenced Based Practices (EBPs)• ACT• Medication Management• Family Psychoeducation• Integrated Mental Health and
Substance Use Services• Illness Self Management
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Evidenced Based Practices Gaps in access to these services due to
the complexity and fragmentation of the current healthcare system • Administered by different systems
with different rules• Subject to different funding streams
Explore expanding relationships to allow for coverage of these critical services
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CareSource Care Management
Case and Disease Management Clinical Care Advance Care Management Support Services Special Needs Plan
• Medicare Quality Improvement Medical Management/Utilization Management Triage/Clinical Call Center Behavioral Health/Controlled Substance Member
Management Business Analysts
Behavioral Health Services
Traditional Case Management Intensive Case ManagementCARE4U Case ManagemetBridge to Home
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Behavioral Health Team The BH Team consists of Case and Medical
Management for members with BH needs BH Medical Management team is comprised of:
• Patient Care Coordinators (PCC) - RNs and SW• Prior Auth Specialists (PAS) - non clinical
administrative support• Psychiatric Consultants
Case Management team is comprised of: • RN’s, SW and Psychiatric Consultants • Case Management includes care for Low,
medium and high stratification members and a BH Intense Case Management Program
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Reliance on Partnerships
State and County Government Agencies
Service Providers
Advocacy organizations
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