Reminder Effective Service Coordination in a Person-Centered Program
In a person-centered program such as the ADvantage waiver program, effective care coordination is paramount in ensuring Members receive timely and appropriate service delivery that most effectively meets their needs, values and preferences. Care coordination is an effective way of both improving the quality of care provided as well as lowering the overall costs of care to our high need population.
As Member advocates and responsible fiscal stewards, it is the duty of the provider community to engage in communication and coordination to ensure the best possible outcome for our Members.
All service providers must make every effort to encourage self-reliance by involving the Member and their designated family, friends and community resources in the development and implementation of the person-centered service plan. Doing so enhances and strengthens the Member's supports, promotes independence, prevents further loss of function, and increases the ability of the Member to remain safely in their home.
Adults who are older and/or have disabilities are among the highest utilizers of medical care and support services. As such, they are at high risk for receiving fragmented care, at high cost, and with poor health outcomes. As care providers, we all have the responsibility to consistently monitor for changes in need and/or service utilization and respond accordingly. Some changes that might be identified include but are not limited to:
- An increased or decreased need for supply items (for example, incontinence supplies, either stockpiling, or insufficient to last until the next delivery)
- A change in dietary requirements (for example a freezer full of uneaten home delivered meals because the member is too ill to eat or does not like the meal options)
- Continued weight loss even with the delivery of nutritional supplements
- A reduced need for personal care assistance when the Member moves in with family or gains additional support
- A Personal Emergency Response System (PERS) device that is never online and is never tested
- The need for a service that is not provided through the ADvantage waiver or other paid resources
- It is important to note that providers are responsible for identifying not only the need for a change in paid services, but also for identifying the Member's needs for services not provided through the waiver, and for supporting the Member to access those needed services.
A key aspect of person-centered service delivery is the concept of having a single person accountable to each individual member. For the ADvantage waiver, this person is the Case Manager (CM). In the event a change in Member need or circumstance is identified by a service provider (home care, home delivered meals, DME providers, etc.), it is the responsibility of that service provider to immediately inform the Member's case manager so appropriate action can be taken in a timely manner. The use of the Provider Communication form (ADv9/02CB009E) is an excellent tool to ensure the CM is aware of the needed change and Documentation of this communication must be kept in the service provider's Member chart. Within 5 business days of notification to the CM of a change in the Member's need, the service plan amendment is submitted to the MSU-AA within five calendar days of assessed need (OAC 317:35-17-14).
In the event there a service delivery need or issue cannot be resolved at the agency level, the MSU-AA has an Escalated Issues department to assist with any conflicts, barriers, or problems. This team may be contacted via SmarterMail to MSU Provider Question at the address listed below.
By having a knowledgeable Case Manager, a dynamic care planning process, and a responsive provider network all focused on the person we serve, we can make important improvements to the care and outcomes of ADvantage Members.
If you have any questions regarding the information provided above, please feel free to contact us via SmarterMail at: firstname.lastname@example.org