Slide 1: Care Partnership
Implementation Council THP Unify Update
June 11, 2019
Care Coordination
Presented by: Bea Thibedeau DNP, RN, Program Director
Slide 2: Context
•	Overview: Model Of Care
•	Interdisciplinary Care Model
•	Case Study Responses 
•	Conclusion and Discussion
Slide 3: Program Goals:
Improve access to and coordination of medical, behavioral and social services that can reduce unnecessary and preventable admissions, emergency room visits, facility based care, while promoting self directed care and independence for its members 
•	Member is central to the care planning process
•	An interdisciplinary care team (ICT) model is key to effectively coordinate care and services for members across the care continuum
o	Member chooses the ICT membership, engages in and drives their care planning and evaluation process
o	Primary care engagement 
o	LTS C active participant
Critical Success Factors: 
•	Member Engagement
•	Provider Engagement
•	Care Management
Slide 4: Philosophy of care management model Monitoring quality
“Nothing about me without me.”
•	Our care model is member-centric and focused on the needs, values and preferences of individual members
•	Our efforts focus on areas where we make a meaningful difference for our members
•	Care planning is inclusive and based on the principle of shared decisions between members and their interdisciplinary team
•	Care management strategies follow the member’s “personal” commitment to overall health management and self-direction
•	Care coordination is best supported through an integrated care delivery model
Footnote: Gorski, David. “Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?”. Jul 20 2010. https://sciencebasedmedicine.org/dr-donald-berwick-and-patient-centered-medicine-letting-the-woo-into-the-new-health-care-law/
Slide 5: Care Management Approach:
As the primary source of contact for the member, the care manager is responsible for working with the member and based on preferences, to:
•	Develop the individualized plan of care, based on ongoing assessment
•	Work with the member to manage their plan of care
•	Ensure continuity of care whenever possible
•	Coordinate services on the member’s behalf
•	Promotes the role of the LTS C as an advocate and ensure that LTSS services are provided when needed
•	Manage the member’s care transitions
•	Help to remove barriers to care
•	Arranging home and community-based services, including transportation to medical appointments
•	Educating the member and caregiver(s)
•	Serve as a strong member advocate
Slide 6: Care Management Approach: 
As the primary source of contact for the member, the care manager is responsible for working with the member and based on preferences, to:
•	Develop the individualized plan of care, based on ongoing assessment
•	Work with the member to manage their plan of care
•	Ensure continuity of care whenever possible 
•	Coordinate services on the member’s behalf
•	Promotes the role of the LTS C as an advocate and ensure that LTSS services are provided when needed  
•	Manage the member’s care transitions
•	Help to remove barriers to care
•	Arranging home and community based services, including transportation to medical appointments
•	Educating the member and caregiver(s)
•	Serve as a strong member advocate
Slide 7: Behavioral health model of care / Example
Diagram is small, medium, and larger circles.
The small circle contains: 
•	Member (Inclusive of advocate and family)
The Medium circle contains (surrounds the small circle): 
•	Interdisciplinary Care Team
•	Specialists and Other Ancillary Providers
•	Long-term Services and Supports (LTSS)
•	Other Member Supports
•	Tufts Health Plan Care Manager
•	Primary Care Provider (PCP)
The Larger circle contains (as surrounds the Medium circle):
•	Emergency Services Program
•	Enhanced Acute Treatment Services
•	Community Support Services
•	Clubhouse
•	Acute treatment Services (detox)
•	Peer Support
•	Psychiatric Day Treatment
•	Community Crisis Stabilization Services
•	In-home therapy
•	Structured Outpatient Addiction Program
•	Group Counseling
•	Partial Hospitalization Program
Tufts Health Plan’s model of care is designed around an interdisciplinary care team that is member-focused.
Coordination of health services, including mental health, substance use, and primary care, is necessary to achieve positive outcomes for people with complex health care needs.
The member’s care manager is the primary point of contact and works with the member and their LTS C to ensure coordination of services and member progression toward goals
Title Slide 8: Case Studies Analysis and Care Management Approaches
Slide 9: Andrea: Traumatic Brain Injury
Profile
•	Complex member with cognitive deficit
•	Social isolation
•	PCA compensates for service gaps  
•	Lack of knowledge re: benefit
•	Barrier to self direction  
•	Care manager not responsive 
•	Lack of advocacy / Fear 
•	Member rights/protection
Care Management Approach
•	Comprehensive Assessment
o	Psycho-social
o	Functional / Safety
o	Risk Profile
•	Access LTSS 
o	LTS C / Advocacy
o	CSP / Peer support
o	Non medical transport
•	ICT
o	Access and setting of care 
o	Care coordination 
o	Member choice 
o	Address barriers
o	PCA boundaries  
Slide 10: Bernie: Auto Accident
Profile
•	Loss of independence / Chronic pain / Limited mobility / falls
•	Social isolation
•	Lack of member engagement based on past experience with his care team
•	Attempts to self direct care (transportation, purchases walker)
•	Care manager not engaged / lack of empathy and advocacy
•	Depression / Relapse risk
Care Management Approach
•	Comprehensive Assessment 
o	Psycho-social assessment 
o	Functional / Safety
o	Risk Profile
•	Access LTSS 
o	LTS C
o	CSP / Peer support
o	Non medical transportation
o	Personal Care 
o	DME
•	ICT
o	Home safety/Physical Therapy 
o	Pain management
o	Social Stimulation
o	Depression Treatment 
Slide 11: Conclusions / Discussion
•	Assessment Process drives care planning and care coordination 
•	Member engagement optimizes the assessment and care planning process
•	Leverage LTS C whenever possible
•	Leverage ICT to advance the member’s care plan and progression
•	The relationship the member has with their care manager is critical
•	Knowledge of benefits and advocacy drives self direction
•	Influencing members without taking charge