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Sunshine Health Tango Plan

Long-Term Care (LTC)

Objective

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• Overview of our Long-Term Care (LTC) product.

• Discuss how services are accessed - Integrated Care Model.

• Discuss care coordination and case management.

• Discuss trainings for providers and staff.

• Define both behavioral management and behavioral health.

• Answer any questions and address concerns regarding Integrated

Care Model.

Long-Term Care (LTC)

Overview

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Nassau

Sumter

Clay

Charlotte

Polk

Flagler

Hardee

DeSoto

St.Johns

Volusia

Orange

Okeechobee

Brevard

IndianRiver

Palm Beach

St.Lucie

Broward

Miami-Dade

Okaloosa Walton

Escambia

Wakulla

Madison

Franklin

Jackson

Calhoun

Hamilton

Lafayette

Dixie

Suwannee

Gilc

hrist

Citrus

Pasco

Hernando

Bra

dford

Marion

Hillsborough

Manatee

Sarasota

Duval

Putnam

Lake

Lee

Osceola

Monroe

Seminole

Collier

Highlands

Glades

Hendry

Martin

SantaRosa

Leon

Jeffer

son

Bay

Gulf

Holmes

Was

hingt

on

Liberty

Gadsden

Taylor

Levy

Col

um

bia

Alachua

Baker

Union

PinellasRegion 1

3/1/14

Region 3

3/1/14

Region 4

3/1/14

Region 5

2/1/14

Region 6

2/1/14

Region 7

8/1/13

Region 8

9/1/13

Region 9

9/1/13

Region 10

11/1/13

Region 11

12/1/13

Nassau

Sumter

Clay

Charlotte

Polk

Flagler

Hardee

DeSoto

St.Johns

Volusia

Orange

Okeechobee

Brevard

IndianRiver

Palm Beach

St.Lucie

Broward

Miami-Dade

Okaloosa Walton

Escambia

Wakulla

Madison

Franklin

Jackson

Calhoun

Hamilton

Lafayette

Dixie

Suwannee

Gilc

hrist

Citrus

Pasco

Hernando

Bra

dford

Marion

Hillsborough

Manatee

Sarasota

Duval

Putnam

Lake

Lee

Osceola

Monroe

Seminole

Collier

Highlands

Glades

Hendry

Martin

SantaRosa

Leon

Jeffer

son

Bay

Gulf

Holmes

Was

hingt

on

Liberty

Gadsden

Taylor

Levy

Col

um

bia

Alachua

Baker

Union

Pinellas

LTC Service

Area 1

LTC Service

Area 2

LTC Service

Area 3

LTC Service

Area 4

Orlando/

Pensacola

Jacksonville

Tampa

Sunrise

LTC Leadership

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Regions 1 & 7

Roni Zaletel, Executive Director

Carolyn Smith, Dir., Case Mgmt.

Regions 3

Donna Melogy, Executive Director

Pam Bertwell, Dir., Case Mgmt.

Regions 9, 10, 11

Amie Fernandez, Executive Director

Mayra Infanzon, Dir., Case Mgmt.

Regions 5, 6, 8

Greg Abdouch, Executive Director

Erica Colon, Dir., Case Mgmt.

Pam VanKoevering, Mgr., Ops &

Enrollment

Kathy Rupp, Mgr., Provider Relations

Carey Merzlicker, Dir., Finance

Tracy Celebrado, Mgr., LTC Contracting

Denise O’Driscoll, Mgr., Claims

Dona Leith, Cenpatico Clinical Mgr.

Sunshine Health LTC Provider Services

Phone # 877-211-1999

David Wagner, VP of LTC

LTC Members

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• Individuals 65 years of age or older who need a nursing facility

level of care.

• Individuals 18 years of age or older who are eligible for Medicaid

by reason of a disability and need a nursing facility level of care.

• Individuals who live in a nursing facility.

• Individuals enrolled in one of the following programs:

• Aged and disabled adult waiver

• Consumer-Directed Care Plus for individuals in the above

waiver

• Adult day health care waiver

• Assisted living waiver

• Channeling services for frail elders waiver

• Program of all-inclusive care for the elderly

• Nursing home diversion waiver

Who is on the team?

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Integrated Care Team Members (IC T)

• Member

• Family / Natural Supports

• Medical Directors

• Integrated Leadership team

• Case Manager

• Program Coordinator / Specialist

• BH Coordinator

• Disease Management Health Coach

• Pharmacy Director

• Utilization Managers

• Member Connections Representative

• LTC Trainer & Behavior Management Specialist

Collaboration

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Working together for the good of the enrollee.

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The Sunshine Health case management model is based on

supporting our members in a holistic manner.

The model considers the member’s physical health and

behavioral health conditions and diagnoses as well as their

social, environmental, financial, cognitive, spiritual, cultural

and functional status.

Integrated Holistic Approach

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Some members have both physical and behavioral health

conditions. The presence of these conditions may have an impact

on the member’s ability to access care and manage their conditions.

In many cases, both physical health and behavioral staff are

supporting the member. Ongoing and frequent dialog occurs

between the staff managing the member and with the member’s

treating providers.

Overview of Integrated Care

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Coordinated physical health, mental health, and substance abuse

treatment to provide the best possible outcomes for our members.

Integrated Healthcare

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Enrollee Touch Points

Document CP and Auths in TruCare

Member Calls MSU

EligibilityBenefits

Materials

Care PlanAuthorization

Care Coordination

Type of Call

Document activity in CRM

Connections

Member Services

Transportation Coordinator BH CoordinatorKey Accountability: Transport Key Accountability: Crisis

Management

Key Accountability: Transition Assistance/Community Support

Key Accountability: First Call Resolution and Call Routing

Document services in TruCare.

TransportNeeds

Review needs with CM. Coordinate

services with vendor.

Assessment and Care Plan

Development

TransportNeeds

Communicate with MemberPost Service F/U

Assist with crisis management,

provider referral and/or engage CBH

Review medical services

Assist with member transitions,

Medicaid pending, Connections Plus

UMKey Accountability: Medical Necessity Review and Over/

Under Utilization

Document notes in TruCare

Concurrent ReviewKey Accountability: Discharge Planning

Work with hospital on discharge

planning back to community setting

Document discharge plan in Trucare

Discharge Plan

Medical Review

Key Accountability: Assessment and Care

Planning

Case Management

Document XFER in CRM

Document auth in TruCare

Face to Face Visit

Face to Face VisitsTelephonic OR

Care Plan Development

Document notes in TruCare

Telephonic de-escalation and referral

BH Needs

Key Accountability: Administrative Support to

CM

Program Coordinator

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Case Management

What to expect?

• Case Manager (CM) will contact facility to notify them of assigned

members – Administrator, Director of Nursing, Social Worker, and

Business Office Manager are potential contacts for the CM’s.

• CM will contact member’s responsible party if necessary to review new

enrollee handbook, member benefits, required forms, etc.

• Consent from member’s responsible party is not required to complete

member needs assessment and the CM will proceed in order to meet

ACHA requirements and to complete service authorizations.

• Based on facility membership only 1-2 CM’s will be assigned for

continuity of care and consistent communication.

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Case Management What to expect?

• CM will review meet with the member and review the medical record

including the MDS, MAR’s, Care Plan, Progress Notes, MD Orders, etc.

• Copies of Demographic Sheet, MAR’s, POA, Advanced Directives may be

requested.

• SNF members are to be seen within seven business days of enrollment date

and ALF/Home members within five business days

• Case Manager will complete a new member Needs Assessments and

develop a member centered plan of care.

• Reassessment of members needs is completed on at least a quarterly basis.

• Contact by phone or in person is made on a monthly basis to each member

to ensure their safety, well being and if any additional services are needed.

• Enrollees residing and remaining in the nursing home setting are exempt

from the annual level of care redetermination requirement.

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Care Coordination

Sunshine Health has mechanisms in place to promote coordination and

communication across disciplines and departments, with particular

emphasis on ensuring coordinated approaches with medical management

and quality management. This includes such mechanisms as the following:

• Interdepartmental communication among staff with Enrollee contact,

Case management, Enrollee Services, Utilization Management, Med

Management and Quality Management. CM and QM and MM staff (as

well as other staff with Enrollee contact) have access to TruCare and

are able to share data.

• Case Manager’s participate in weekly Clinical Rounds which are

attended by the Medical Director, Clinical Resource Specialist, BH

Coordinator, Director of CM and Interdisciplinary staff to review complex

cases & facilitate coordination of care, appropriate utilization of services,

and identify additional service options based on IDT recommendations.

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Case Management – Home Based Care Plan Management

• Initiated Weekly Discharge Planning Rounds (Acute Care/Rehab).

• Attendees: CM, CM Supervisors, Medical Director,

Behavioral Health CM, Clinical Resource Specialist (CRS),

CR (NHT CM Sup), DCM, and ED

• Created Discharge Planning Tool (v4).

• Weekly Complex Case Discussion (placement, high cost care

plans, under utilization/over utilization (two hours).

• Case Conferences as needed.

• Attendees: CM Supervisor, appeals and grievance

coordinator, CRS, CM, and Directors

• Fair hearings

• Appeals/Grievances

• Behavioral Health – integrated to all meetings as needed.

Time lines

• Case Manager is assigned immediately upon member enrollment

• Case Manager must make initial onsite visit and complete Care Plan within 5 business days

• Case Manager must follow up with enrollee or representative telephonically within 7 business days after initial contact and Care Plan development

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Time lines

• Monthly telephone contact

• Review of Care Plan in a face-to-face visit every 90 days (more often if enrollee requires changes to be made)

• Annual face-to-face visit to reassess enrollees needs and develop a new Plan of Care

• Case Manager must forward Plan of Care within 10 business days of development to PCP and ALF

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Time line for Case Managers

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• Review of Care Plan in a face-to-face visit every 90 days (more often if enrollee requires changes to be made)

• Annual face-to-face visit to reassess enrollees needs and develop a new Plan of Care

• Case Manager must forward Plan of Care within 10 business days of development to PCP and ALF

• If the recipient is enrolled in both an MMA and LTC plan, the LTC plan is responsible for CC.

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Case management [Assessing and Care

planning]

Behavioral Health

Coordinator [Crisis

management]

Clinical Resource Specialist [Medical necessity review]

Enrollee connections

[Transition assistance/Enroll

ee support]

Program Coordinator [Case mgmt.

admin support needs]

Transportation Coordinator

[Transportation scheduling]

Concurrent Review

[Discharge planning]

Integrated Care Team Approach and Support Staff

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• Case Manager during assessment process will determine behavioral

health need

• Case Manager will staff case during weekly meeting with ICT

• Once need is identified BHC will contact member and

identify/coordinate services within 48 hours

• BHC will either telephonically or in person contact member and will

also contact facility for behavioral management services & training

• BHC is used as a resource for the Case Manager to determine needs

• Participates in case review during Clinical Rounds

Case Management – LTC Behavioral Health Coordinator

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Service Planning and Coordination

The case manager collaborates with the Enrollee/representative, family,

Primary Care Physician (PCP), network, and non-network providers

and community resources to develop, implement and monitor a

comprehensive, cost-effective plan of care based on enrollee/family

strengths, needs, goals, and preferences.

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• Trainings

• Behavioral Health

• Behavioral Management

Cenpatico Services

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Behavioral Management : A short term intervention to assist with the management of a new or change in a behavior.

• Identify triggers to specific behaviors.

• Short term behavioral modification and facility trainings.

• Support to the member and facility/caregiver through the development of a plan to modify behaviors.

• Provided by a Cenpatico contracted Community Mental Health Centers (CMHC).

Behavioral Health: Ongoing treatment of a psychiatric illness or a mental health diagnosis.

• Treatment to include crisis intervention of a psychiatric crisis, counseling/therapy, targeted case management, and medication management.

• Accessed through the Medicaid Managed Care Organization (MCO).

Behavioral Management vs. Behavioral Health

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We use behavioral management to help our member stay in their

placements and have the highest quality of life.

Behavioral Management Services

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• If an enrollee is having a behavioral issue, during regular

business hours or after hours the caregiver or facility may

contact the Community Mental Health Care (CMHC) directly.

• There is no referral needed and will receive up to eight hours of

behavioral management help.

• The CMHC is required to respond within two hours of the

request.

Behavioral Management Services Access

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How do I request this?

• During office hours you may contact the member’s case manager

at Tango to initiate the request.

• After hours you may contact the CMHC contact for your regional

area to initiate the request.

Behavioral Management Services Access

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The services are used to maximize reduction of the enrollee’s disability

and restoration to the best possible functional level and may include,

but are not limited to:

• Evaluation of the origin and trigger of the presenting behavior.

• Development of strategies to address the behavior.

• Implementation of an intervention by the provider.

• Assistance for the caregiver in being able to intervene and

maintain the improved behavior.

Behavioral Management