8 Health Care Management Services
8.7 Care Transition Protocols and Management
Assisting with the management of transitions is an important part of our case management and model of care. Members are at risk of fragmented and unsafe care during transitions between care settings and levels of care. To help members and caregivers navigate transitions successfully, assistance is provided through many touch points and through educational materials. Transitions in care refer to the movement between health care providers and settings and includes changes in a member’s level of care.
Examples of transitions include transitions to and from: acute care, skilled nursing facility, custodial nursing facility, rehabilitation facility, home, home health care, and outpatient or ambulatory care centers. A team approach is necessary to assist the member with a successful transition. Managing transitions includes protocols such as assisting with logistical arrangements, providing education to the member and care giver, coordination between health care professionals and a provider network with appropriate specialists who can address complex needs. Transitional care includes both the receiving and sending aspects of the transfer.
Transitional care management assists in providing continuity of care by creating an environment where the member and the provider are cooperatively involved in ongoing health care management with a goal of providing access to high-quality, cost-effective medical care.
Personnel Responsible for Coordinating Care Transition
Managing transitions in care is a responsibility of the interdisciplinary care team (ICT). The membership of the team varies based on the complexity of the member’s needs and the desires of the member and type of transition. The team consists of providers, the member and/or care giver, and members of our care management team and/or Community Health Workers.
Providers are essential members of the ICT and should assist members by coordinating care and communicating with members of the ICT. Members are connected to the appropriate provider to care for their individual needs including any complex medical conditions. The PCP is responsible for coordinating and arranging referrals to the appropriate care provider. The provider network includes providers who have an expertise in managing the health care needs. Some of the provider types available in our network to manage the special need of this population include but are not limited to:
When services are not a covered benefit, coordination with community resources occurs to meet the needs of the population. For our dual population, you are required to coordinate between Medicare and Medicaid. Coordination with Medicaid services includes coordination of benefits and also working with Medicaid case managers/service coordinators and providers of long-term services and supports (LTSS) to close care gaps.
Protocols outlining the expectations for managing transitions may be communicated to the provider network through newsletters, published in the provider manual or on the provider portal. Those protocols include the following guidelines:
- Manage the medical and health care needs of members, including monitoring and following up on care provided by other providers, providing coordination necessary for services provided by specialists and ancillary providers (both in and out-of-network)
- Provide coverage 24 hours a day, 7 days a week
- Provide all services ethically, legally and in a culturally competent manner, and meet the unique needs of members with special health care needs
- Provide members complete information concerning their diagnosis, evaluation, treatment and prognosis and give them the opportunity to participate in decisions involving their health care, except when contraindicated for medical reasons
- Advise members about their health status, medical care or treatment options, regardless of whether benefits for such care are provided under the program and advise them on treatments that may be self-administered
- When clinically indicated, contact members as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiological findings
- Participate in the interdisciplinary care team meetings
- When a member experiences a transition in care, it is the responsibility of the transferring provider to do the following:
- Notify the member in advance of a planned transition
- Provide documentation to the provider or facility about the member to assist in providing continuity of care
- Communicate and follow up with the member about the transition process
- Communicate with the member about his or her health status and plan of care to prevent any gaps post transition
- Provide a treatment plan/discharge instruction to the member prior to being discharged from one level of care to another
- The referring physician or provider should provide the relevant patient history to the receiving provider
- Any pertinent diagnostic results should be forwarded to the receiving provider
- The receiving provider should communicate a treatment plan back to the referring provider
- Any diagnostic test results ordered by the receiving provider should be communicated to the referring provider
We assist our members and providers in the management of transitions in multiple ways. The actions below represent some of the ways our care team works with our providers and members to coordinate care:
- Communicates with the provider to discuss the member’s care needs as identified during case management or model of care activities.
- Assist the member in making appointments
- Coordination between Medicaid and Medicare benefits
- Perform medication reconciliation
- Arranging transportation
- Refer to external or internal programs
- Coordinate care with behavioral health
- Assist with arranging durable medical equipment (DME) and home health services
- Coordinate and facilitate transitions to the appropriate level of care
- Provide the member with disease specific education and self-management techniques
- Contact high-risk members post discharge to reduce unnecessary readmissions
- During interactions with the member, communicate support is available from member services to serve as a central point of contact and assist during any transition