MI HEALTH LINK ACRONYMS AND KEY TERMS

Transcription

1 MI HEALTH LINK ACRONYMS AND KEY TERMS MI Health Link - New program that will integrate Medicare and Medicaid benefits, rules and payments into one coordinated delivery system DOCUMENT FORMAT Acronym/Key Term - Complete Term if Applicable Definition of the acronym/key term Explanation of the acronym/key term as it applies to MI Health Link KEY PLAYERS DWMHA - ICO - MCPN - MME - Detroit Wayne Mental Health Authority The Authority is responsible for managing specialty services for Consumers with or at risk for serious emotional disturbance (SED), severe mental illness (SMI), developmental disabilities (DD), substance abuse, and MIChild beneficiaries. We are the Community Mental Health Service Provider (CMHSP) for Wayne County. The DWMHA is the organization spearheading the MI Health Link program. Integrated Care Organization A health insurance-based organization contractually responsible and accountable for providing integrated care to people eligible for both Medicare and Medicaid. The ICOs participating in Wayne County's MI Health Link program are Aetna Better Health of Michigan, AmeriHealth, Fidelis SecureCare, HAP Midwest Health Plan, and Molina Healthcare. Manager of Comprehensive Provider Network The DWMHA contracts with MCPNs to manage a full array of speciality behavioral health services. This management is meant to ensure the appropriate type, frequency, and quality of health care services. MI Health Link enrollees undergo a multi-level assessment process upon enrollment and this assessment places them into either the Mild/Mod category or the SMI/I/DD category. Those identified as SMI/I/DD are enrolled with a MCPN to help manage their behavioral health care. Medicare-Medicaid Enrollee This is someone who qualifies for both Medicare and Medicaid coverage. These are also known as dual eligibles or duals. These are the consumers who can qualify for the MI Health Link

2 program, as long as they are age 21 or over, reside in a demonstration region (Wayne County is Region 7), and are not enrolled in hospice. PIHP - Prepaid Inpatient Health Plan Organizations that the Department of Community Health contracts with to manage the Medicaid covered community mental health benefit. For Wayne County MI Health Link enrollees, all behavioral health services covered by Medicare and Medicaid will be managed by PIHPs. CARE TEAM FACILITATORS ICO Care Coordinator - Provider Level Case Manager or Supports Coordinator - PIHP Supports Coordinator - The ICO Care Coordinator is a resource offered to each MI Health Link enrollee and is the facilitator of the enrollee s ICT. This person must be a Michigan licensed registered nurse, nurse practitioner, physician s assistant, or Bachelor s or Master s prepared social worker employed or contracted with the ICO. The individual facilitates communication among the MI Health Link enrollee s providers, including physicians, long term supports and services providers and behavioral health providers. They will also help connect enrollees to other community-based social services to help them live as independently as possible. An individual at a contracted provider who works with a consumer on health care goals. Not all providers have this service for consumers. This professional should be invited to participate as a member of the enrollee s ICT and therefore assist in their person-centered planning process. The supports coordinator is a member of the ICT who is available to enrollees who have been identified as having BH, I/DD, or SUD needs. This individual collaborates with the enrollee and their ICO care coordinator to assure all necessary supports and services are provided to the enrollee. LEVEL ASSESSMENTS Level I Assessment - Level II Assessment - A comprehensive assessment of an enrollee s medical, psychosocial, cognitive, and functional status in order to determine their medical, behavioral health, LTSS, and social needs. This assessment also identifies consumers as having a SUD or I/DD. It must be completed within 45 days of enrollment start date. This process triggers Level II assessments- practices that begin the formation of personalized health care for the enrollee. Completed by the DWMHA within 15 days of the Level I Assessment for people identified with mental health or substance use disorder (SUD) needs, intellectual/developmental disabilities needs (I/DD), or long term

3 supports and services (LTSS) needs. Level II consists of multiple assessments: a screening for people with Behavioral Health needs (done via the ASAM, LOCUS, or SIS) and the Bio-Psychosocial assessment. The Michigan Nursing Facility Level of Care assessment for people needing Nursing Home or Waiver Services is also completed as necessary during Level II, but this process is done by the ICO. Supports and services will be coordinated for MI Health Link enrollees to meet the needs identified through these assessments. LEVEL II ASSESSMENT TYPES ASAM Assessment - Bio-Psychosocial - LOCUS Assessment - SIS Assessment - American Society of Addiction Medicine Assessment The ASAM assessment consists of a comprehensive set of guidelines for placement, continued stay, and transfer/discharge of patients with addiction and co-occurring conditions. This assessment fulfills the DWMHA's Level II Behavioral Health screening requirement for new MI Health Link enrollees. This assessment should be filled out for active enrollees identified as having a SUD and any enrollees who are not active with the DWMHA. The Bio-Psychosocial assessment systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. The DWMHA is required to complete this assessment for all new MI Health Link enrollees in order to ensure a coordinated, whole-person healthcare experience. Level of Care Utilization System Assessment Assesses the enrollee s needs based on level of functioning through six evaluation dimensions. This assessment determines a recommendation for level of care. This assessment fulfills the DWMHA's Level II Behavioral Health screening requirement for new MI Health Link enrollees. This assessment should be filled out for active enrollees identified as Mild/Mod and is also an option for enrollees identified as SMI/I/DD. Supports Intensity Scale Assessment The SIS assessment is a scientific assessment tool specifically designed to measure the level of practical supports required by people with intellectual disabilities. This assessment fulfills the DWMHA's Level II Behavioral Health screening requirement for new MI Health Link enrollees. This assessment is one of the options for active enrollees identified as SMI/I/DD.

4 OTHER IMPORTANT TERMS ADT - BH - Care Bridge - CMHSP - HRA - ICT - Admission, Discharge, Transfers This is the record of a consumer s health care service usage in terms of admissions, discharges, and transfers. The DWMHA s UM Department receives a copy of each enrollee s Behavioral Health ADT. UM reviews this record and the results of this review are uploaded to MH-WIN. If necessary, the ICT team and/or ICO Care Coordinator will be notified of concerns regarding the ADT. Behavioral Health Behavioral health services assist people with needs related to a mental illness, intellectual/developmental disability and/or substance use disorder. Sometimes these services are referred to as mental health services. All Medicaid and Medicare behavioral health services are covered by MI Health Link. The care coordination framework for Michigan s integrated care efforts. The Care Bridge includes an electronic Care Coordination platform which will support an Integrated Care Bridge Record to facilitate timely and effective information flow between the members of the ICT. Through the Care Bridge, the members of a MI Health Link enrollee s ICT facilitate formal and informal services and supports in conjunction with an enrollee s person-centered care plan. Community Mental Health Service Provider CMHSPs are government entities that, along with the organizations with which they contract, provide a comprehensive range of services and supports to children, adolescents and adults with mental illnesses, developmental disabilities and substance use disorders. Wayne County s CMHSP is the DWMHA. Health Risk Assessment This is another term for the Level I Assessment. Integrated Care Team An ICT, led by the ICO Care Coordinator, will be offered to each MI Health Link enrollee. Membership will include the enrollee and the enrollee s chosen allies, primary care physician and, as applicable, LTSS Supports Coordinator and PIHP Supports Coordinator. The enrollee and team may also include other providers who are needed. This team is there to help MI Health Link enrollees get the care they need. Together with the enrollee, the ICT develops the IPOS/IICSP and

5 coordinates services and benefits to meet the goals identified in that plan. IPOS/IICSP - LTSS - MDCH - MH-WIN - MI Choice - Individual Plan of Service/Integrated Individualized Care and Supports Plan The IPOS/IICSP is a plan for the coordinated, efficient care and support of a MI Health Link enrollee, which includes assessment results, a health summary, care preferences and priorities, service usage, a plan for addressing health concerns, as well as the responsible parties and due dates for each goal. Through the assessment and the person-centered planning process, the IPOS/IICSP will be developed with each enrollee, their ICO care coordinator, and their ICT to identify the supports and services that will best meet their needs and care goals. ICT members will provide timely access to care and services identified in the plan and communicate plan facilitation through the Care Bridge. Long Term Supports and Services Services for consumers who experience difficulty living independently and completing daily self-care activities as a result of cognitive disabilities, physical impairments, and/or disabling chronic conditions. Medicaid LTSS are delivered in institutional settings (e.g., nursing facilities) and community-based settings (e.g., private homes). MI Health Link covers enrollees for all LTSS that are covered by Medicare and Medicaid. Need for these services is determined through the Level I & II Assessments. Michigan Department of Community Health MDCH is responsible for health policy and management of the state s health, mental health, and substance use care systems. As the state government entity responsible for health care, they work closely with the DWMHA and other MI Health Link-affiliated organizations to ensure the program s smooth adoption. A variety of resources on MI Health Link can be found on their website at Mental Health Wellness Information Network MH-WIN is DWMHA s main information system, used for the secure maintenance of protected health information (PHI). This system is used to securely share MI Health Link documents such as the Level I Assessment. MH-WIN is also used to share information regarding which consumers are enrolled in the program, the results of higher level of care requests, and many other MI Health Link-related functions. MI Choice is a statewide program designed to give older adults and people with disabilities more choices in receiving long term supports. It provides a variety of services in a person s home that are similar to those

6 provided in a nursing home. Participants of MI Choice have to leave that program to join MI Health Link. Michigan Enrolls - Mild/Mod - PACE - PCP - SMI/I/DD - SUD - Michigan Enrolls offers information about Medicaid health plans and can tell consumers which doctors and specialists are part of each health plan. Their phone number is ENROLLS. If consumers have questions about enrollment or disenrollment in MI Health Link, they can call Michigan Enrolls toll-free. Persons with hearing and speech disabilities may call the TTY number at MIld/Moderate Consumers who fall into this category require healthcare services, but not to the same intensity level as those in the SMI/I/DD category. Need for these services is determined through the Level I & II Assessments. Enrollees who fall into this category are not serviced by a MCPN. If an enrollee falls into this category, they are not in the SMI/I/DD category- they are mutually exclusive. Program of All-Inclusive Care for the Elderly A Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. Participants of PACE have to leave that program to join MI Health Link. Primary Care Provider This professional is responsible for providing and coordinating the enrollee s health care needs, including the initiation and monitoring of referrals for specialty services when required. PCPs may be nurse practitioners, physician assistants or physicians who are board certified, or a specialist selected by an enrollee. Primary Care services insured through Medicare and Medicaid are covered for all MI Health Link enrollees. Severe Mental Illness/Intellectual/Developmental Disabilities This category of consumers includes people with a range of conditions that require intensive healthcare services. MI Health Link insures enrollees for all SMI/I/DD services that are covered by Medicare and Medicaid. Need for these services is determined through the Level I & II Assessments. Enrollees who fall into one of these categories are serviced by a MCPN in addition to their ICO and the DWMHA. If an enrollee falls into this category, they are not in the Mild/Mod category- they are mutually exclusive. Substance Use Disorder Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as

7 health problems, disability, and failure to meet major responsibilities at work, school, or home. MI Health Link insures enrollees for all SUD services that are covered by Medicare and Medicaid. Need for these services is determined through the Level I & II Assessments. If an enrollee falls into the SUD category in addition to the Mild/Mod category, they are not serviced by a MCPN. If they fall into the SMI/I/DD category, they are serviced by a MCPN. UM - Utilization Management This department of the DWMHA provides oversight and monitors MCPNs and Centralized Access Center s delegated Utilization Management (UM) functions, which include Access and Eligibility, Service Authorization and Utilization Review. The UM Department handles reviews of higher level of services requests and ADT reports. The results of these reviews will be uploaded to MH-WIN and the appropriate ICT members will be notified when applicable.