ADMINISTRATION
Removing Barriers to Care The role and impact of health plan care coordinators BY AMY REWEY, FLORENCE OKOAMPA, KATHLEEN KEOGH, APRN, CNP, DIANE ANDERSON, RN, BSN, CCM AND HEATHER QUIST, RN
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n the shared pursuit of improving health outcomes, reducing costs and enhancing the patient experience, health plans and their partners have realized that a collaborative approach to care management is far more efficient than going it alone.
Enter the care coordinator, who brings all these goals together for the benefit of the member. Care coordinators within a health plan assist their members by streamlining health care across the continuum. This may include navigation of benefits, help with insurance prior authorization, managing appeals processes and accessing basic services. These complexities can create additional stress and delays in care for members. With case management, the coordinator works with providers, hospital staff and community-based organizations to ease the burden. Health plan care coordinators, for instance, can work with members to help them access stable housing, healthy food, reliable transportation to appointments and financial assistance. There are several ways a care coordinator can be assigned to someone. Some insurance products, like Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+)—which cover members 65 and older who have Medicaid and Medicare benefits— automatically provide a care coordinator. Other products use various reports and referral sources to determine if a member needs care management. There are also complex medical conditions—such as cancer, eating disorders, high-risk pregnancies, renal disease and gender care—in which a coordinator would be assigned to a member. Family members or the members themselves can also request care coordination depending on the health situation. Care coordination leaders from Minnesota’s nonprofit health plans shared their perspectives on how they work toward their goal of ensuring whole person care for their members. They also shared how their work can improve health equity and access to fundamental needs.
What is a Care Coordinator? The care coordinator role includes assisting members through: • Assistance in establishing care with a primary care physician. • Education on health-related conditions and preventive health screenings. • Coordination with other agencies including the county, community resources and providers. • Support during member transitions, including creating a safe transition plan. –Kathleen Keogh
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APRIL 2022 MINNESOTA PHYSICIAN
Why does a health plan have a role in coordinating care for members? We have a unique vantage point to identify gaps in care and set goals to reduce gaps in equitable care. At HealthPartners, we work closely with our care delivery partner to ensure best outcomes. As both a health plan and care system, providing care coordination helps us live up to our mission and values. It also makes access to care, benefits and services easier and more efficient for members. By developing a trusting rapport, we help them navigate the complex health care system and connect them with the appropriate support entities across the continuum of their benefits. We can easily connect with others in the HealthPartners system to reduce gaps in care and reduce hospitalizations. A care coordinator can also access claims information on supplies, equipment or care received elsewhere. –Florence Okoampa
With whom do care coordinators work to bring that holistic experience to members? Describe how a care coordinator might work with these folks to promote better outcomes for members. Care coordinators use a collaborative, interdisciplinary approach. This provides access, resources and support for members to maintain optimal health and achieve their health care goals. The partners they work with include: • Providers: Care coordinators assist members in establishing care with a primary care physician and with accessing specialty providers including mental health, dental care and others. They support a member’s access to their providers by assisting with transportation to appointments and assisting members with scheduling appointments. • Hospitals/Nursing facilities: Care coordinators maintain communication and provide support during periods of transition with a stay in a hospital, rehabilitation center or nursing facility. They participate with discharge planning to support the member’s care plan, provide continuity of care and to assist members to achieve positive outcomes upon discharge. • Community-based organizations: Care coordinators work with other agencies, including county services, community resources and providers to address social drivers of health, such as housing needs, care services (such as home care, nursing or therapy) and medical supply needs. Collaboration with the county includes working with county-based financial workers, case managers and regulators to help ensure the member receives the care and support they need. • Interdisciplinary health plan team members: Care coordinators work collaboratively with pharmacy, behavioral health, case management and others to coordinate care, identify and assist with any gaps in care and support the member’s individualized plan of care and health needs. Care coordinators may also collaborate with a member’s family, guardian or power of attorney to support the member’s care and needs. –Kathleen Keogh
