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Developing a Point of Contact (POC) with Member and Family to Meet Unique Needs

“Our member is in her 90s and homebound. She enjoys being active and having visits from friends and neighbors. However, the COVID-19 pandemic resulted in her experiencing increased social isolation and reduced care and support from family members, including those who served as her caretakers.

Our member’s Healthy Connections Prime health plan care coordinator spoke with her and her family to identify her immediate and long-term needs. The care coordinator discussed with them waiver services she may qualify for through Community Long Term Care (CLTC), and together, they tailored a care plan specific to the member and her caregiver’s situation. Further coordination with a Waiver Case Manager provided the member support with various aspects of personal care including Activities of Daily Living, food preparation, housekeeping tasks, and a medical alert call system in case of emergencies. In addition, biweekly in-home provider visits were implemented for the member. The member and her family were grateful and pleased that these services were available.”

Care Coordinator Compassion and Dedication

“A care coordinator with one of our health plans experienced difficulties reaching one of our members due to the member’s discomfort speaking to a care coordinator. The care coordinator was concerned about the member’s health and his many hospital admissions and continued to reach out to the member to build trust. Over a few months, the member recognized the value of the care coordinator and was able to accept various services including home health, transportation to medical appointments, home delivered meals, waiver case management, and custodial care. A few years later, the member had to enter a skilled nursing facility due to his declining health. The trust that was built up between the care coordinator and member resulted in the member proactively keeping in constant contact with his care coordinator during his skilled nursing facility stay. He and his care coordinator collaborated with a social worker on understanding the member’s needs. The team successfully developed a care plan to allow him to begin physical therapy and regain this ability to be more active. The member’s Medicare- Medicaid Plan (MMP) applauded this care coordinator’s compassion and dedication.”

Connecting Caregiver to Nursing Home Resources for Member

“One of our members suffers from chronic obstructive pulmonary disease (COPD) and was also hospitalized with COVID-19, leading to an inability to walk independently. He needed help with

Activities of Daily Living. His wife had been his caretaker but had health challenges of her own that she needed to address. The member’s doctor advised that a Long Term Care facility would be the best option and helped them get a referral and subsequent approval for a nearby nursing home. The member’s wife was happy to have this option so that recovery could be quick and the member could return home. The member’s wife told the care coordinator, “This has been a huge challenge to coordinate this for my husband. Thank you for all you have done for us!”

Care Coordination Helps Address Various Member Needs

“One of our members has greatly benefited from care coordination over the years of being with his Medicaid-Medicare Plan (MMP). When he had difficulty establishing a comfortable primary care experience (particularly during the pandemic), his care coordinator was able to help him get set up with in-house primary care visits. The care coordinator also helped resolve a pharmacy bill concern as well as help the member, whose phone was broken, get a new phone. Additionally, the member needed help with Activities of Daily Living but expressed the desire to maintain his independence. The care coordinator helped him get a referral and approval to enroll in a Community Long Term Care (CLTC) waiver. Overall, he is appreciative and a testament to the mission and vision at the MMP.”

Safe Discharge and Ongoing Community Waiver Services Support to Help member Remain Safely at Home

“One of our members who had recently been hospitalized was subsequently readmitted due to a worsening of his condition. He was sent to an acute rehabilitation facility post-discharge to regain his strength and was having trouble connecting with a home health agency. His waiver case manager and care coordinator worked together to set up a home health assessment and approval for Community Long Term Care (CLTC) Community Choices waiver services. The member expressed gratitude that these individuals were able to work together with him, his family, and the facility to create a safe discharge plan and provide ongoing support through the CLTC Community Choices waiver services. He was able to avoid readmission and will be able to safely remain in his home while he continues to recover and regain his strength.”

Leveraging Community Resources to Meet Member’s Vision Needs

“Through routine outreach by health plan staff, it was found that one of our members was in
need of prescription glasses as his vision was impaired. Although he was able to complete an eye exam, he and his family were unable to afford prescription glasses. The Medicare-Medicaid Plan’s (MMP) care coordinator was able to connect the member with an organization that

provided a free pair of prescription eyeglasses to those who need them but are income limited. The glasses were ordered successfully without any additional financial burden on the member. The MMP helped find a solution to close the gap in health inequities. The ability to see is very important to help the member achieve his best state of health.”


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