Dream, Empower, Achieve!
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Transcript of Dream, Empower, Achieve!
Dream, Empower, Achieve!
April 26, 2012
Our ExperienceOur Experience
• Centene has 28 years experience
• Currently serves over 1.6 million Medicaid members This includes about 218,000 Aged, Blind and Disabled individuals
• Has health plans in over 15 states
Membership: 194,900
Membership: 305,800
Membership: 90,300
Membership: 36,200
Membership: 160,100Membership: 215,800Membership: 74,900Membership: 22,400 Membership: 433,100Health PlansStates with Health Plan Membership
States with Centene Operations
Implementing Health Plans
Centene Headquarters
Headquarters for CenCorp Companies
Centene Claims Processing Centers
Health Plans not yet pictured:
•Home State Health Plan (MO)
•Coordinated Care (WA)
IlliniCare’s Member with Developmental IlliniCare’s Member with Developmental Disabilities ProfileDisabilities Profile
• The “average” IlliniCare member with a developmental disability has the following characteristics: Is Male Lives in Cook County Is on average 34 years old
• Population Break Down: Sex
Male: 60% Female: 40%
County Cook: 67% Will: 10% DuPage: 8%
Lake: 7% Kane: 5% Kankakee: 3%
The Integrated Care DreamThe Integrated Care Dream
• Connecting a fragmented delivery system Bringing together medical, behavioral and social services Open communication between providers, member and health
plan
• Medical Home Member sees one Primary Care Physician and builds a strong
relationship with that provider That provider oversees health needs, helps with referrals,
specialty care, etc.
• Coordinating Care Linking members with needed services and providers Ensuring members get the right care, at the right time, in the
right setting
The Full Picture of HealthThe Full Picture of Health
Physical HealthMental Health
Social Services
Integrated Care
Making the Integrated Care Dream a RealityMaking the Integrated Care Dream a Reality
• Person-centered Care plan is unique to each member’s goals for their own health Services and programs are wrapped around the individual, customized to
their needs and preferences
• Integrated Team of Experts Assist members to navigate the system Work with current organizations/agencies as an additional advocate If members do not have this additional support, we will provide it
• Innovative Programs MemberConnections Connections Plus CentAccount
IlliniCare’s Model of Member-Centered CareIlliniCare’s Model of Member-Centered Care
Pharmacist
ConnectionsTeam
Behavioral Health
Provider
CommunityLiaison
Integrated Care Teams
24 Hr.Nurse Advice
Line
CommunitySupports
Medical PCP
MedicalDirector
MEMBER
• Behavioral Health Service Coordinator Licensed clinician with experience in
service coordination
• Medical Service Coordinator Licensed RN clinician with experience
in service coordination
Integrated Care TeamIntegrated Care Team
• Social Worker Licensed and non-licensed with experience in directly coordinating and
integrating the social/community needs of members
• Program Coordinator Helps the member navigate the system; assists in coordinating care,
setting up appointments, identifying physicians, etc.
IlliniCare currently has nine Integrated Care Teams
Integrated Care Team – Focused on Members with Integrated Care Team – Focused on Members with Developmental DisabilitiesDevelopmental Disabilities
• Specialized experience with individuals with developmental disabilities
• Each individual is touched by every member of the team
• Team works together to find solutions for members
• Noelle Ficarello, Program Specialist – Social Work 10 years of Social Services experience Licensed Clinical Social Worker Worked at residential treatment center for children with emotional and behavioral disabilities,
adults with chronic mental illness, and adults with mental illness and a developmental disability
Meet the Team:
Meet the Integrated Care TeamMeet the Integrated Care Team
• Elizabeth Audiffred, Program Coordinator 18 years experience Worked with low income families, care management and case worker programs
providing services to Medicaid enrollees
• Kathy Schneider, Medical Care Coordinator 19 years experience Registered Nurse Worked in SNF, home health care and hospice. Worked for six years as the Health
Services Director for Community Living Services at Little Friends, Inc.
• Stacey Stewart, Behavioral Health Care Manager 15 years experience Licensed Professional Clinical Counselor Worked directly with children, adolescents and adults with developmental disabilities
providing therapy and case management Providing counseling and support groups for caregivers of people with developmental
disabilities
Covered Benefits – Medical Covered Benefits – Medical • Doctor Care
Yearly Physical Exams Specialists Visits Wellness Visits Diagnosis and treatment Immunizations (shots) Prenatal and postpartum care
• Medical Supplies: Durable Medical Equipment Disposable medical supplies Prosthetic devices
• Hospital Care Inpatient services Outpatient services Laboratory X-ray Diagnostic studies Emergency care Surgeries
• Other Covered Services: Physical Therapy Chiropractic care Occupational therapy Hospice
Covered Benefits – Dental & VisionCovered Benefits – Dental & Vision
• Dental covers: Fillings Crowns (caps) Root canals Dentures Extractions (pulling)
• Vision covers: Yearly eye exam 1 pair of glasses per year
• IlliniCare Extra Benefits: Enhanced Frame Selection Contact Lenses
X-Rays Annual cleaning
for adults Practice visits if
needed
Physical Health – How We HelpPhysical Health – How We Help
PCP Relationship Assist in finding a PCP Working with providers that are
both in and out of network Educating providers on ICP,
continuity of care Annual Doctors Visits
Educate members about procedures and assist them to feel comfortable
Explain tests, next steps Practice Visits for dental services
and OBGYN appointments
Additional needs: Medical Equipment Dental Optical
Preventive Health Screenings: Flu shots Immunizations Annual pap and
mammogram Colorectal cancer
screenings
• Integrated Care Team ensures members are in good physical health. We help members with:
Covered Benefits – Behavioral HealthCovered Benefits – Behavioral Health
• Behavioral Health services include:
Mental Health assessments
Psychological evaluations
Treatment plan development
Substance abuse treatment
Crisis intervention
Therapy
Counseling
Developmental testing
Medication training
Behavioral Health – How We HelpBehavioral Health – How We Help
• Mental health affects physical health. By addressing behavioral health and medical issues together, we help members be healthier.
• Connect members with behavioral health services they need: Psychiatry Psycho-social rehab Group therapy Individual therapy
• Connecting with community agencies – the member’s local care management team Integrated Care Team doesn’t replace member’s current supports Additional advocate if needed
• Coaching – helping member understand services and process of behavioral health appointments
Medication management Substance abuse Smoking Cessation Support Groups
Covered Benefits – Pharmacy Covered Benefits – Pharmacy
• Preferred Drug List Includes list of medications that are
covered by IlliniCare. Providers must prescribe the
medications on the PDL Exceptions made if it is
medically necessary Ensure covered medications are used
to treat a variety of conditions and diseases
Entire Preferred Drug List is available online
• Over the counter drugs on preferred drug list We will cover the cost if you have a
prescription from your physician
• Filling a prescription Use an in-network pharmacy Receive 90 day supply by mail
with RxDirect
Covered Benefits – Transportation Covered Benefits – Transportation
• IlliniCare will provide transportation when needed. This includes: Reimbursement of personal mileage Door-to-Door service PACE Service Medi Transport Public Transportation
• We will select the best transportation method for the member’s needs based on: Proximity to the home/provider Accessibility needs Cost effectiveness
• Contact Member Services at 866-329-4701 to arrange transportation. Member Services will ask a series of questions to
determine the best transportation option Please contact us at least 72 hours before the
appointment
Social Health – How We HelpSocial Health – How We Help
• Having the proper support through family members, friends and the community and living fulfilling lives
• Having a safe home and access to social resources
Safety in the Home Electricity Running Water
• Providing Resources Support Groups Advocacy Organizations
Social Services Financial Assistance Housing Food Assistance
Helping Members Achieve THEIR DreamsHelping Members Achieve THEIR Dreams
• Goal Setting Part of Care Plan Not just health goals, but life goals
• Goal Examples: Following the treatment plan Going back to school – GED/College Remaining independent Living in the community Reaching their full potential Employment
• How IlliniCare helps: Coaching, guiding, empowering Finding resources Assistance in navigating the system
Empowering MembersEmpowering Members
• PCP Selection Allowing members to choose their provider
• Involved in Care Plan Creation We involve member in every step of the process along with PCP and community care team
Member’s health and personal goals contribute to overall care plan
• Coordinating Transportation Giving member the freedom and power to travel to/from their appointments
• Connections Plus Program If qualified, give member access to cell phone to connect with IlliniCare, Care Team, PCP
and familial supports
• CentAccount Program Reward members for healthy behaviors
Empower members to purchase health-related items with a pre-paid debit card
What does Integrated Care Achieve?What does Integrated Care Achieve?
• Care that is delivered at the right time, in the right setting
• Improved Health Outcomes
• Access to Preventive Care
• Independent Living in the Community
Success StoriesSuccess Stories
“I want to write, here, how happy and pleased I am with IlliniCare. I had to choose a new plan and I am so grateful I chose yours.” - Mary Y., in response to receiving the member newsletter
“I just wanted to take a quick minute and let you know, as a marketer myself, how refreshingly impressed I was. I wasn’t looking forward to having to deal with an HMO for one of our patients for PA, until I started dealing with the employees. And one that particularly stands out is Lisa Kimbrough –but they are all great. Everybody’s very efficient, they call you back, there’s no attitude; it doesn’t drag out. Blue Cross should hire your staff.” - Sharon Ballor, Applewood Rehab, Marketing & Admission Director
“It is good to know IlliniCare is so dedicated to the health of its members. Thank you as well for assisting me with this housing dilemma. As you (so rightly) said, ‘housing is a part of health.’”-Veronica, after working with the integrated care team
“He should get some sort of employee of the year award just for taking care of my problems. I can’t thank him enough for all the rigmarole he had gone through on my behalf.” - Debbie L., after working with the Integrated Care Team on behalf of her daughter, an IlliniCare member.
“We really, really do appreciate the transportation service provided through the IlliniCare Plan. You guys are way ahead of the competition. In fact, there is no competition because other companies will be following you.” - Katrina T., caregiver of IlliniCare member
Dental SuccessDental Success
Member Name: Derrick*
Stats: 23 years-old, male
Diagnosis: Autism, mental retardation and epilepsy
•Derrick’s mother contacted ICT. he was experiencing pain, fever and mouth swelling. She requested help from the ICT.
•Directed Derrick to his PCP to treat the infection; member had a tooth abscess.
•Unable to tolerate dental exam, needed IV sedation.
•Next step was to treat the abscess. Worked with the members preferred dental provider.
•SCA put into place for the member’s preferred anesthesiologist.
Terri, a program specialist with IlliniCare worked with the member and
his mother to get him the care he needed.
• The entire process involved a collaboration of the Integrated Care Team, IlliniCare management and contracting, providers, and the member's mother working together for the optimal outcome for the member.
• The end result was the member received the necessary treatment on February 22nd.
*Members name changed to protect confidentiality
Encouragement is a part of healthEncouragement is a part of health
• Angela is a great advocate for herself, so Chris also referred her to Equip for Equality.
• Chris is currently helping Angela work with the Department of Rehabilitation in order to get the services she needs such as a homemaker and meals on wheels.
• Angela recently went to one of our members-only health events. At that event she raved about Chris, and how much he was doing on her behalf.
Member Name: Angela*
Stats: 56 years-old, female
Diagnosis: Traumatic brain injury, multiple brain aneurisms, seizure disorder
• Chris contacted Angela to complete the HRA. She was in need of DME, including a shower bar and a C-PAP machine. Chris was able to refer her to the appropriate providers to get what she needed.
• Angela did not like the PCP she was automatically assigned to, so Chris helped her find a new PCP. She has been seeing her doctor regularly, and likes him a lot.
• Angela explained that she felt lonely; she has never met someone in her situation before. Even when she spoke to others that have had an aneurism, she felt they couldn’t understand her.
• Chris encouraged Angela by explaining that she could help other people who are having a hard time recovering, since she’s been through two aneurisms. Chris gave her the information for the Brain Injury Association of Illinois, so she could join a support group. She had never considered that perspective, and is contacting them to join a support group.
Chris, a program specialist, helped a member with her
medical needs, as well as her emotional needs.
*Members name changed to protect confidentiality