Person centered, holistic approach, using a team-based care model
Indicators for Referring to VCCI: Members with complex health and social needs and who would benefit from a team based care model and our priority population served are individuals who do not have any connections with health care +/or service providers in the community and who would benefit from a team based care model. If the member does have an established primary care provider, please work with them prior to/along with sending a referral. VCCI can provide consultation as requested.
- Member has comorbidities (new or prior dx), including mental health/substance use disorder and a need for monitoring of treatment plan or medication adherence; needs coordination with health-related resources including housing, food, transportation
- Member would benefit from community-based visits to support treatment plan, plan of care or redirection to patient centered medical home.
- Member is new to Medicaid and needs orientation to the system of healthcare (i.e. PCP, Dental) and healthcare related resources (i.e. housing, food).
- High ED utilization, frequent hospitalization, poly pharmacy and/or high predictability of future health care complications.
- Medical, behavioral, and/or psychosocial instability, leading to gaps in care.
- Intensive case management, one on one intervention required (e.g. home visits).
Eligibility Criteria:
- Be enrolled in a full Medicaid program (no VPharm, etc.); maybe dually insured.
- Not currently receiving other case management services (e.g. CMS covered case management such as CRT, Choices for Care and/or other waivers).
- Not currently residents of nursing homes, assisted living facilities or correctional facilities.
Case Management Role: Overall responsibilities include Advocacy, Assessment, Planning, Implementation, Coordination, Monitoring, Evaluation, and using a team-based care service delivery model. The nurse case managers:
- Engage in the team-based care model using patient engagement tools (domain cards, eco/relationship maps), establishes shared care plans, helps identify lead care coordinator, convenes +/or facilitates +/or participates in care conferences.
- Facilitate access to a medical home and communication/coordination among service providers.
- Develop a plan of care for health and health related needs management based on the priority of both the member, with input from providers and social factors impacting health outcomes.
- Facilitate communication and coordination among member, PCP and specialty providers, and community partners to support the treatment plan, including mental health and substance abuse providers.
- Support development of skill and confidence required for effective self-management of chronic conditions and navigation of complex system of care via coaching, education, and/or referral to programs and/or services (Certified diabetic educators, Healthier Living Workshops).
- Orient members to the system of care to include navigation of services for health and health-related needs such as primary care and dental access, housing, food security, transportation, fuel assistance.