Care Coordination

Members may have many different types of external care team Members. It is important to coordinate care for our Members so care is not delivered in silos but in a collaborative approach that best fits the Member’s needs. All external communication should be documented in a case note utilizing the Care Coordination with external providers intervention. This includes Case Management Meetings, Child and Family Team Meetings with DCS, etc.

When the communication is successful, select the engagement status of successful, substantive engagement with non-member. For other outcomes, use appropriate options.

External Care Team Coordination Template:

D: Healthy Blue Care Team and Mindoula Care Team reviewed Member records for Coordination of Care.

A: Member is very engaged in the program, he is having consistent issues with his transportation failing to pick him up for his appointments with specialists.

P: Healthy Blue provided additional case management services related to transportation. Healthy Blue was encouraged to see Member’s high level of participation in care as that has not historically been the case.

The internal care team may include Managers, Leads, OECs, Care Extenders, Peers, or Therapists. SUDP utilizes a multi-disciplinary team approach in which monthly case conferences are required and are to be documented by the therapist. Managers will also review cases with the primary care team Members. There also may be times when Multi-Program Collaboration is needed between IVRP, SPP, MPMP and/or SUDP. Utilize the “Mindoula Care Team Coordination” for all of these types of notes.

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Care Team Coordination Template:

D: Therapist and Peer reviewed Member records for Coordination of Care.

A: Member is very engaged with the peer but continues to miss the intake with the therapist. Member has had a difficult history in therapy and does not see that it will be an advantage to him.

P: Peer will invite therapist to next Peer Visit with Member’s permission so that the intake can be completed and to assist in building rapport between the Member and therapist.

Managers will also review charts with the primary care team members. These reviews should be documented as Mindoula Care Team Coordination as well.

Clinical Rounds are held on the SUDP team the first week of the month. Internal Clinical Rounds

The Program Manager keeps a spreadsheet monthly to track which cases are needed to discuss. Those are held in the 304 Drive in the Clinical Rounds folder.Clinical Rounds

Peer Lead documents the note with the selected intervention, “Mindoula Care Team Coordination.”

Clinical Rounds Template:

D: Mindoula Team reviewed Member records for Coordination of Care.

A: Member recently disclosed a relapse to her therapist and has been avoiding the peers calls. The RAP has not yet been completed.

P: Therapist and Peer will coordinate with the Member to meet as a group in order to complete the RAP and set the Member up for success with recovery.

Peer and Therapists are assigned a “work buddy.” When new Members are enrolled, where possible, the same peers and therapists are assigned to increase ability for coordination of care. When a member of the care team is out on PTO, it is the responsibility of the alternative buddy to ensure that the Member is outreached and cared for during their absence, this does not require an additional outreach unless the other team member has flagged the Member as high risk and asked for additional support. If a team Member is unexpectedly absent, it is up to leadership discretion as to how Members will be notified e.g. by the buddy or the leader. Managers should ensure that buddies are not on PTO at the same time.