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July 26, 2018


Medicaid New Five-Year Contract Begins January 1, 2019

As explained in previous articles, we are providing analysis of the upcoming new Statewide Medicaid Managed Care contract effective January 1, 2019. This week is focused on the state Agency for Health Care Administration (AHCA) Statewide Medicaid Managed Care (SMMC) Program Goals.

AHCA provided a SMMC update on July 10, 2018, to the Medicaid Medical Care Advisory Committee, emphasizing the SMMC Program Goals below.

Two of these goals have significance to the nursing home community: (1) to reduce potentially preventable hospital events (PPEs) - Admissions, Readmissions, Emergency Department Visits; and (2) to increase the percentage of enrollees receiving long-term care services in their own homes or the community instead of a nursing facility.

There are multiple ways these goals will be met through various interventions by the health plans. One focus area will include utilizing their care coordination/case management staff with an emphasis on patient centered care. The care coordination/case management section of the contract has detailed direction and specific requirements both for visiting the enrollee and reporting to AHCA. One such direction is the Plan of Care Standard. Below is a small portion of that direction for an example:

If you are interested in reviewing the entire section of this contract to further understand why or to explain to the resident’s family the case manager’s interview requests, please contact me.

In the coming weeks we will explore the other new requirements of the contract and how these requirements will potentially affect providers.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909.

Goals of Care Discussions in Long Term Care

A hot topic in long term care is “person-centered care.” In fact, the latest guidance for managed care plans state that:
…LTC services and maintenance therapy services (occupational, physical, respiratory, and speech therapy), the Managed Care Plan shall ensure that services meet … one of the following:
(d) Enable the enrollee to maintain or regain functional capacity; or
(e) Enable the enrollee to have access to the benefits of community living, to achieve person-centered goals, and to live and work in the setting of his or her choice.

Because the Managed Care Plan is expected to do this, it is certain that they will expect us to accomplish this task.

What exactly is “person-centered care?” It really is the latest evolution of “patient-centered care” and applies more clearly to those in long term care as much of the “care” that is provided is not in the medical realm. The Institute of Medicine identified patient-centered care as one of the six pillars of quality health care and described it as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” In 2015 the American Geriatric Society published a position paper with a useful definition of person-centered care.

“Person-centered care” means that individuals’ values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals.”

A key term in this definition is the addition of life goals to the usual medical discussion. Thus, person-centered care is not just about discussions of end-of-life care, but really about how the person wants to live, regardless of the time left.

The foundation of person centered care is a discussion about goals of care. Again, we have to be careful not to think too narrowly about either the person’s goals or their care. Perhaps unfortunately, we have all been so focused on developing “care plans” that we tend to have a fixed idea of what they contain. A goal of care discussion includes that but goes beyond what is traditionally seen as a care plan. An initial goal of care discussion upon entry into the long-term services and supports system is critical to providing person-centered care. Furthermore, it needs to be repeated over time and especially when the person’s status changes.

So – what is involved in a goal of care discussion? The first step is always determining what the resident understands of his or her situation. A first step might be:

What is your understanding of your present situation?

This provides an opportunity to clarify any misunderstandings and offer more information about available choices. This often opens the door to the next question:

What is most important to you in your life right now?

This question often is the first opportunity a resident has been given to talk about his or her goals and can be very meaningful to the resident. After some further clarification of what is important a useful question to elucidate the resident’s goals is:

What would you like to see happen over the next year in your life?

At this point it is important to simply listen attentively, asking probing follow-up questions. If there are scenarios that are unlikely to occur (e.g., “to go back to living in my own home”) it is best to wait until the next conversation to develop a deeper understanding of the resident’s thoughts on this matter. Too early presentations of “reality” will only set the resident up to being in an adversarial position. A better approach is to acknowledge the resident’s concerns and views. A statement like:

I hear what you saying that you would like to see x, y, and z happen in the next year. I look forward to talking more about that with you.

There are other questions that can be used when discussing specific questions such as intensity of care or end-of life decisions. These will be addressed in future articles.

This obviously not a one-time event in a resident’s life. Such discussions are the foundation of high-quality care and need to be repeated as the staff come to know the resident more deeply and especially when the resident’s situation, medical or otherwise, undergoes significant changes.

Ken Brummel-Smith, MD
Medical Director, FAHA H&S
Professor Emeritus, Florida State University College of Medicine

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.

Person-centered care: A definition and essential elements, J American Geriatric Society, 2015, DOI: 10.1111/jgs.13866


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Health plan updates

Staywell, WellCare’s Medicaid health plan has provided an updated Florida Medicaid Provider Resource Guide.This guide explains how to access their provider portal and all the capabilities within the portal. Read the Guide...

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Principal/Editor: Dana McHugh

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