The Challenge
In August 2011, Medicare Advantage Special Needs Plan faced a dilemma.
It was assuming responsibility for recertifying the care needs of an additional 1,200 low income elders who were receiving personal care services from the state. The time frame for completion was short and recertification required completion of complex state mandated forms.
Moreover, service recommendations had to be directly related to clinical need. Not just any “objective” evaluation of these individuals in their home would suffice. Recertifications could not be performed by a service provider in whose interest it was to certify an ongoing need for services.
The Solution
LifePlans had successfully been providing in-home bathroom safety and fall prevention assessments to more than 10,000 Medicare Advantage Special Needs members for over three years. So the Plan called LifePlans for help.
In very short order, LifePlans:
- Reviewed its nursing coverage in the service areas to determine whether more nurses would be needed to conduct these assessments in a timely fashion.
- As is often the case, LifePlans National Clinical Network was extremely robust and therefore additional recruiting efforts were not needed
- LifePlans began a very extensive training effort of its clinical field network in the proper use of the state-mandated forms.
- LifePlans uses a very sophisticated distance learning and evaluating platform to get its clinical network members up to speed quickly while ensuring the highest possible levels of quality assurance
- Training was quickly deployed to the field and home visits commenced
The Results
The contact data on these low income individuals was not always reliable. Working with the Plan, LifePlans made multiple attempts to visit individuals to complete the assessment and develop service recommendations.
LifePlans used both scheduled and unannounced visits to get to members.
- LifePlans clinical staff reviewed every completed assessment
- LifePlans developed a custom data analytics application to assure that service recommendations were always made within guidelines presented by the state
- LifePlans’ robust quality control program assured that when information from the assessment arrived at the Plan, it was reliable, objective and actionable
Over the period, LifePlans was successful in completing roughly 85% of valid cases. This helped to assure that members could continue to receive needed services uninterrupted, and that the Plan had a strong clinical basis for the provision of services that it was paying for.