transcript

transcript  One Care: What you need to know about care coordination and care planning

music Hello, and welcome.

0:09

9 seconds

My name is Jeff Keilson.

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11 seconds

I'm a member of the Implementation Council and the President of the Board of  the Disability Policy Consortium.

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17 seconds

This video is presented by  the Implementation Council, a group of consumer members and community-based  advocates who closely partner with MassHealth and health plans to improve One Care.

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30 seconds

Today, we're discussing the essential  role Care Coordinators play in One Care, and how care coordination  can support and empower you.

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39 seconds

In One Care, your care team  includes your care coordinator, providers, and the supporters you choose, all working together with you at the center.

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50 seconds

Your care coordinator is your partner  in both health and daily life.

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55 seconds

By understanding your goals, priorities,  and what matters most to you, they help create care that  supports you as a whole person.

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1 minute, 4 seconds

Your care coordinator helps build and  update your care plan, coordinate services, adjust supports as your needs change, and assist  with appeals or grievances when issues arise.

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1 minute, 17 seconds

Hi, my name is Dennis Heaphy, and I am  the Chair of the Implementation Council.

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1 minute, 21 seconds

I am going to talk to you about  the importance of your care plan and to do so I am going to share  with you a little bit about Julia, a One Care member.

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1 minute, 30 seconds

Julia as a One Care member, has a care plan and that care plan  plays a key role in her everyday life.

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1 minute, 39 seconds

It defines the services and supports she receives and clearly documents what matters most to her.

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1 minute, 46 seconds

Julia learned early on that her  care plan is a living document. As her goals, needs, or circumstances change, her care plan can change too.

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1 minute, 56 seconds

And she has a right to make  changes to her care plan.

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1 minute, 59 seconds

With support from her care coordinator,  and other members of her care team, Julia makes sure her care plan  reflects more just than medical information.

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2 minutes, 9 seconds

It includes her mental health  needs, her recovery goals, her independent living goals, and her desire to live a  full life in the community.

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2 minutes, 19 seconds

And that includes things like staying  connected with friends, family and doing things that are important to her.

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2 minutes, 27 seconds

Whether it be art therapy,  support groups, or just spending time with friends and family.

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2 minutes, 34 seconds

By documenting details about her  daily life and the barriers she faces, such as unreliable transportation  or changes in the home situation,

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2 minutes, 44 seconds

Julia's care plan captures her real needs rather  than just what appears in her medical record.

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2 minutes, 52 seconds

Because Julia's needs and priorities are clearly written in her care plan,  services can be better coordinated

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2 minutes, 58 seconds

and supports can be adjusted when things change. When parts of Julia's care plan

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3 minutes, 5 seconds

did not fully meet her needs, she learned she had the right to speak up and work with the care coordinator  and work with the care team and appeal decisions.

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3 minutes, 16 seconds

And that is important. You have a right to appeal decisions. Her care plan helped her clearly explain  what was missing and why it mattered.

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3 minutes, 26 seconds

Today, Julia sees her care  plan as something she owns.

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3 minutes, 30 seconds

It is a tool that she can  use to help shape her care, her goals, and her future on her terms.

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3 minutes, 38 seconds

Hi, my name is Bella Rose, and I am one of the  Co-Vice Chairs of the Implementation Council.

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3 minutes, 46 seconds

Before I had my current care coordinator,  I didn't always feel supported.

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3 minutes, 52 seconds

I often felt rushed, like I didn't matter, or that I had to figure things out on my own.

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4 minutes

Eventually,  I realized it was okay to ask for a new care coordinator and that  decision changed everything.

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4 minutes, 9 seconds

Now I work with Maeve, and from the very  start, she treated me like a person.

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4 minutes, 15 seconds

She took the  time to listen  and really understand my needs,

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4 minutes, 20 seconds

not just medically, but in my day to day life. Because she understands my situation, she helps connect me to the services  and supports that I actually need.

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4 minutes, 33 seconds

She's helped find providers  who can come to my home.

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4 minutes, 37 seconds

She made sure my doctors and services  are communicating with each other, and helped things stay on track  when there were changes in my care.

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4 minutes, 47 seconds

She's also helped me find community supports  and in home services when things changed, so I could keep getting  what I needed without gaps.

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4 minutes, 57 seconds

One of the biggest ways my  care coordinator has helped me was during an appeal.

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5 minutes, 3 seconds

I'd had to go through appeals before, and  they were very stressful and confusing.

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5 minutes, 9 seconds

But this time was completely different. Maeve offered to walk through the process with me, made the phone calls with me, and explained everything along the way.

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5 minutes, 22 seconds

It was the smoothest appeal  I've ever been through, and the denial was overturned in  my favor. That experience showed me just how much a care coordinator  can advocate for you.

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5 minutes, 36 seconds

Most importantly, I feel  comfortable reaching out to her, and confident that my needs are being met.

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5 minutes, 42 seconds

And I want others to know too that  if your care coordinator isn't right, or the right fit for you, you  can ask for someone new.

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5 minutes, 51 seconds

You deserve support, advocacy, and  a partner who truly is on your side.

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5 minutes, 57 seconds

Hi, my name is Crystal Evan and I am one of  the Implementation Council Co -Vice chairs.

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6 minutes, 3 seconds

In closing, here are the main points to remember: Building a strong relationship  with your care coordinator can make a big difference  in your One Care experience.

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6 minutes, 11 seconds

They are there to support you.

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6 minutes, 14 seconds

Be sure to share all your needs,  including what helps you live your life, both inside and outside of healthcare.

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6 minutes, 20 seconds

Work with your care coordinator to keep your  care plan up to date as your needs change.

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6 minutes, 25 seconds

The Integrated Care Team is  invested in making sure your care plan reflects your needs and your goals.

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6 minutes, 31 seconds

Having your needs clearly documented can help  your team better understand what matters to you and work with you to identify the supports  and services that may be available.

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6 minutes, 41 seconds

Thank you for being a part of One Care. Your care coordinator is here  for you, every step of the way.