Qualis Health Alaska Medicaid Case Management Overview

Transcription

1 Qualis Health Alaska Medicaid Case Management Overview Deon Westmorland, RN, BSN, CCM Director, Alaska and Idaho Medicaid & Private Services Advancing Healthcare Improving Health

2 One of the nation s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day Advancing Healthcare Improving Health

3 Qualis Health A private nonprofit organization established in 1974 Regional Office located in Anchorage with staff also located in Fairbanks, Homer and Mat-Su Have provided care management to Alaska Medicaid since

4 Who We Are We are clinicians We respect your clinical judgment We want your clients to receive the necessary and appropriate services 4

5 What We Do We contract with Alaska Division of Health Care Services to review select outpatient procedures, inpatient procedures and provide case management services We answer clinical and technical questions related to Utilization Management and Case Management services and processes We offer telephonic and onsite provider education We provide review support resource accessibility on our web page 5

6 What We Don t Do We do not receive financial incentives to deny or limit services 6

7 To ensure the: Right service Right setting Right level of care Our Goal 7

8 Case Management Overview Team-oriented approach Voluntary case management program utilizing evidence based practices Integrated approach for clients with catastrophic illness and injury Based throughout Alaska and in Seattle 8

9 Case Management Referrals Utilization management Healthcare facilities State agencies Fiscal agent Community providers Family members 9

10 Case Management Referrals Who Should be Referred? Must be eligible for Medicaid or Denali KidCare Medically complex, catastrophic illness or injury High health services utilization and cost How Can I Refer a Patient? 10

11 Referral to Case Management Case Manager Local Toll-free Patricia Blossom (907) (877) Becky Foster (907) (877) Vicki Albert (907) (888) Refer directly to a case manager Call Qualis Health at (888) Fax referral form to (877) Qualis Health website: 11

12 Case Management Referral Form 12

13 Case Management Process Complete case management assessment Develop plan of care Set goals Identify barriers Implement interventions Evaluate outcomes Assess for case closure 13

14 Evidence Based Interventions Motivational Interviewing (MI) Patient Activation Measure (PAM) Medication Reconciliation Face-to-face visits Collaboration with primary physician and the healthcare team 14

15 Care Transitions Failed transition leads to substantial costs, morbidity and mortality Interventions aimed at reliable handoff communication, close follow-up and engagement or activation of patients and families significantly reduce adverse events 15

16 Case Example 36 year old male sustained severe trauma and burns from MVA requiring left BKA. History of right BKA from prior injury Social history: Married, lives in remote village Acute care, LTAC, Rehab 16

17 Plan of Care Transportation Wound care Safety and fall prevention DME needs Pharmacy needs 17

18 Barriers and Challenges Identified Smooth transition of care Complicated discharge back to rural community Coordination of home DME/equipment/supplies Ongoing wound care/education Nutrition 18

19 Interventions Collaborated with local mid-level provider Coordinated/authorized all DME/ equipment/supply needs Supported PCA/waiver application process Education provided surrounding wound care, nutrition, potential complications 19

20 Interventions cont d Ongoing assessment for complications or barriers Identified provider for prosthetic fitting Supported ongoing therapy needs with regional providers Emotional support 20

21 Outcomes Appropriate resource utilization Averted re-hospitalization Obtained needed supplies and equipment in a timely manner Successful clinical outcome 21

22 Team Approach Enhances Care 22

23 Case Discussion Describe a case management example where there is typically a good outcome? What are the characteristics of that type of case? Who are the team members who work together in this example to contribute to positive outcome? What are the barriers that you typically encounter when transitioning patients from a hospital level of care in Anchorage to a lower level of care in a remote village? What cultural considerations present challenges in discharge planning? 23

24 Qualis Health Contact Information Utilization Review -Toll-free phone (800) Toll-free fax (800) Case Management -Toll-free phone (888) Fax referral form to (877)

25 Qualis Health Website Go to Healthcare Professionals Click on Alaska Medicaid Division of Health Care Services alaska-medicaid-division-health-care-services 25

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27 Questions? 27