QUEST Integration – Health Coordination Services

HMSA’s QUEST Integration Plan Health Coordination Services program is a person-centered service-delivery system to ensure that the needs of members with Special Health Care Needs (SHCN), Expanded Health Care Needs (EHCN) and those receiving long term services and supports (LTSS) are met. For members not meeting the requirements for Health Coordination Services, assistance is also available to help providers with members who face unusual or short-term conditions.

For SHCN and EHCN members and those receiving LTSS, Health Coordinators will assist in coordinating QUEST Integration services with other federal programs such as Medicare, as well as other DOH departments, state agencies, and community services, as appropriate for the member.

Health Coordination Services Responsibilities

• Conduct health and functional assessments (HFA);
• Review Health Action Plan (HAP) goals, objectives, and actions with the member and track progress;
• Coordinate, facilitate, and arrange access to services, including home and community based services (HCBS);
• Manage transitions of care;
• Provide continuity of care when members are discharged from a facility (e.g., resolving instances like the prescribed medication is not on HMSA’s QUEST Integration formulary ;
• Identify if significant changes have occurred; if they have, the HC shall complete a reassessment;
• Verify receipt of services;
• Verify satisfaction with providers and services;
• Identify gaps in care and develop mitigation strategies to address the gaps;
• Review if utilization patterns are appropriate and develop mitigation strategies if the patterns are not appropriate;
• Provide health coordination to support the primary care provider (PCP) and other providers in delivering good medical care to members
• Coordinate a team of decision-makers to develop a HAP, including the PCP, other providers as appropriate, the member, and others determined by the member including family members, caregivers, and significant others.
• Facilitate timely communication across the care team to avoid duplication of services and medication errors, including but not limited to discharge instructions and discharge summaries from facilities
• Coordinate services with other providers and community programs such as Medicare FFS and/or Medicare Advantage (MA) plans, the DOH programs excluded from QUEST Integration, and other DHS programs or health plan providers to ensure continuity of care
• Conduct medication management, including regular medication reconciliation and support of medication adherence
• Monitor progress with EPSDT requirements for children
• Train the member on self-management strategies, as relevant
• Screen for social risk factors and develop a mitigation strategy to address needs
• Provide assistance in resolving any concerns about service delivery or providers
• Assist members to maintain continuous Medicaid benefits, including identifying at-risk members and ensuring continuity of care and services

Health Coordination Services for Children with SHCN

A child with SHCN is an individual under the age of 21 years of age who has a chronic physical, developmental, behavioral, or emotional condition, and who requires health and related services of a type or amount beyond that generally required by children. These include the following:

• Children who become pregnant;
• Children with at least one chronic condition such as asthma, diabetes, hypertension, chronic obstructive lung disease;
• Children with cancer, Hepatitis B, C, HIV/AIDS, or tuberculosis;
• Children who take medication for any serious behavioral/medical condition that has lasted, or is expected to last, at least 12 months (excludes vitamins and fluoride);
• Children who are limited in their ability to do things that most children of the same age can do because of a serious medical/behavioral health condition that has lasted or is expected to last at least 12 months (i.e., need assistance with one or more activities of daily living (ADL));
• Children who need or receive treatment or counseling for an emotional, developmental, or behavioral problem that has lasted or is expected to last at least 12 months;
• Children who need or receive speech therapy, occupational therapy, and/or physical therapy for a medical condition that has lasted or is expected to last at least 12 months;
• Children who experience social conditions such as homelessness or have multiple adverse childhood events (ACE);
• Children being discharged from an acute care setting when length of stay is greater than ten (10) days, and children with multiple admissions during a six (6) month period;
• Children who have multiple hospital and emergency department visits during a six (6) month period;
• Children who have a hospital readmission within the previous thirty (30) days of the previous admission; and/or
• Children who have any combination of chronic conditions that have a moderate to high level of severity, and those conditions are not included in the EHCN target group populations.

Health Coordination Services for Adults with SHCN

An adult with SHCNN is one who is 21 years of age or older and has chronic physical, behavioral, or social condition that requires health related services of a type or amount beyond that generally required by adults. These include the following:

• Adults with high risk pregnancies;
• Adults with untreated or unmanaged chronic medical conditions;
• Adults with untreated or unmanaged behavioral health conditions, including substance use;
• Adults with social conditions such as homelessness, food insecurity, lack of financial benefits, and limited English proficiency to negotiate the healthcare system;
• Adults whose use of prescription medication includes the use of atypical antipsychotics, the chronic use of opioids, the chronic use of polypharmacy (e.g., five (5) or more prescription medications), and other chronic usage of specific drugs that exceed the use by other HMSA QUEST Integration adults
• Adults with cancer, chronic Hepatitis B, chronic Hepatitis C, late stage HIV/AIDS or active tuberculosis;
• Adults being discharged from an acute care setting with a length of stay of ten (10) days or longer;
• Adults with multiple hospital or emergency department admissions during a six (6) month period;
• Adults with a hospital readmission within 30 days of the previous admission; and/or
• Adults with any combination of chronic conditions that have a moderate to high level of severity, and those conditions are not included in the EHCN target population groups.

Health Coordination Services for Adults and Children with EHCN

EHCN services are provided to adults and children that meet the qualifications of the EHCN population due to the member having met one or more of the following medical conditions:

• A serious mental illness (SMI)
  • Members who are not enrolled in CCS;
  • One or more serious and persistent behavioral health conditions; or
  • Including a diagnosable mental, behavioral, or emotional disorder which results in serious functional impairment and substantially interferes with or limits one or more major life activity.
• Substance Use Disorder (SUD)
  • Recurrent use of alcohol and/or drugs that causes clinically significant impairment;
  • Health problems;
  • Disability; and
  • Failure to meet major responsibilities at work, school or home.
• Two or more of the following chronic conditions
  • Asthma
  • Chronic obstructive pulmonary disease (COPD);
  • Coronary artery disease (CAD);
  • Congestive heart failure (CHF);
  • Diabetes;
  • Obesity;
  • Chronic renal disease;
  • Chronic liver disease; and
  • Members receiving palliative care
• One of the identified chronic health conditions listed above and one impairment in an ADL
• Any of the identified chronic health conditions listed above and have identified SRF needs and/or high utilization of health services, including emergency department utilization.

Health Coordination Services of Persons Receiving LTSS

All members receiving LTSS will be assessed by a Health Coordinator to determine the health and functional capability of the member and the appropriate strategies and services to best meet the LTSS needs. Health Coordinators for this population have additional responsibilities beyond those listed above:

• Assure institutional Level of Care (LOC) assessment is completed in accordance with QUEST Integration plan requirements;
• Assure that members receiving LTSS receive services through assessment and the HAP as described below;
• Provide options counseling regarding institutional placement and HCBS alternatives;

• Address social needs for member and their family;
• Assess caregivers for potential burn-out for individuals living at home receiving HCBS; and,
• Assist members in transitioning to and from nursing facilities/residential facilities.

Assessments

Health Coordinators will assess a member’s needs in a face-to-face HFA. This will determine the appropriate strategies and services to best meet the member’s needs, taking into consideration the health status, environment, available supports, medical history, and social history of each member.

Reassessments will be conducted annually for members with SHCN, EHCN and for members receiving LTSS and when there is a significant change in the member’s condition, such as, the death of a caregiver, significant change in health status, change in living arrangement, institutionalization, and change in provider if the provider change affects the HAP.

Members Receiving HCBS Not Meeting Institutional LOC

Persons at risk of deteriorating to the institutional level of care are eligible to receive HCBS. Face-to-face annual assessments will be conducted to review and revise the HAP, if needed. A reassessment will also be conducted when significant events occur in the life of a member, such as, the death of a caregiver, significant change in health status, change in living arrangement, institutionalization, and change in provider if the provider change affects the HAP.

Members Meeting Institutional LOC

An annual assessment will be conducted to review the HAP and revise it if needed. All members will receive a reassessment when a significant even occurs in the member’s life, including but not limited to, death of a caregiver, significant change in health status, change in living arrangement, institutionalization, and change in provider if the provider change affects the service plan.

Health Action Plans (HAP)

The Health Coordinator will work with a team of decision-makers, including the PCP, other providers as appropriate, the member, and others determined by the member including family members, caregivers, and significant others to develop the HAP. The HAP for each member in Health Coordination Services will be based on the HFA of the member. It will be person-centered, describe the medical and social needs of the member, and identify all of the services to be utilized, including but not limited to the amount, frequency, and duration of each service, and the type of provider furnishing the services. The HAP also includes a description of how all clinical and non-clinical healthcare-related needs and services will be coordinated, including coordination with outside entities providing supports for the member. The Health Coordinator works closely with the member’s PCP in updating and making changes to a member’s HAP.

For members not meeting institutional LOC, the plan can extend beyond services provided by the QUEST Integration plan, including community resources.

Referring Patients for Health Coordination Services

If you need assistance with a patient that can benefit from or who requires Health Coordination Services, please call HMSA’s Health Coordination Services Intake Line at 808-948-6997 or toll-free 1-844-223-9856 weekdays from 7:45 a.m. to 4:30 p.m.

Revision History