What is Care Coordination?
Care Coordination is a part of Sandhills Center’s managed care system. It is designed to ensure the best of care for people with serious treatment needs.
When consumers’ needs put them in high-risk situations (such as relapse, hospitalization, homelessness, incarceration and/or transition between services), Care Coordinators take special care to link them with the specialty services they need.
Care Coordination is focused on helping individuals across the entire healthcare system. Care Coordinators manage consumers’ care from assessment to various treatments and services.
By working with the individual and their providers, Care Coordinators improve results by effectively utilizing resources.
What Are Special Needs Populations?
Each disability area has a Special Needs Population that is considered to be at high-risk and is served through Care Coordination.
Intellectual Developmental Disabilities (I/DD):
- People enrolled in the NC Innovations Waiver
- People who receive B3 Deinstitutionalization (DI) funding
- People with I/DD who are functionally eligible for ICF-MR level of care but are not enrolled in NC Innovations, the B3 DI funding or an ICF-MR facility.
- People with I/DD who are currently in, or have been within the past 30 days, a facility operated by the Department of Corrections (DOC) or the Department of Juvenile Justice and Delinquency (DJJDP) for whom the LME-MCO has received notification of discharge.
Mental Health/Substance Abuse (MH/SA):
- Adults with severe and persistent mental illness and current LOCUS (Level of Care Utilization System) Level of VI
- Children with Severe Emotional Disturbance or current CALOCUS (Child and Adolescent Level of Care Utilization System) level of IV or are currently in, or have been within the past 30 days, a facility operated by the Department of Corrections (DOC) or the Department of Juvenile Justice and Delinquency (DJJDP) for whom the LME-MCO has received notification of discharge.
- Individuals that have Substance Use/Addiction Dependence diagnosis and current ASAM Level of lll.7 or ll.2D or higher.
- Individuals with an opioid dependence diagnosis and who have been reported to have used drugs by injection within the past 30 days.
- Individuals with both a mental illness diagnosis and a substance abuse/addiction diagnosis and current LOCUS/CALOCUS of V or higher OR current ASAM PPC Level of lll.5 or higher
- Individuals with both a mental illness diagnosis and a developmental disability diagnosis and current LOCUS/CALOCUS of IV or higher
- Individuals with both a developmental disability diagnosis and a substance use/addiction diagnosis and current ASAM PPC Level of lll.3 or higher
What do Care Coordinators Do?
Care Coordination includes the following:
- Identification of Special Needs Population individuals
- Ensuring that a Person Centered Plan is available for all individuals with special needs
- For individuals in identified MH/SA special health populations, ensuring that a Person Centered Plan is completed by the Behavioral Health Clinical Home
- Proactively engaging individuals identified as a member of a special needs population
- Identifying the gaps in needed services and intervening to ensure the person receives appropriate care
- Coordinating services for the individual across the system and with other systems of care, including primary care
- Measuring results of intervention and treatment, including reduction in high-risk events and inappropriate service utilization
- Collaboration with CCNC Care Coordinators to assure that consumers’ medical care is considered in accordance with CCNC/LME/MCO protocols
What can you expect in the Innovations Plan of Care process?
- During the planning process, your Care Coordinator will explain the different services to you and work with you to develop your Plan of Care based on the services you wish to request. Your Care Coordinator will also explain the requirements in the Innovations Waiver around those services.
- Your Care Coordinator will assure that your Plan of Care will include the services that you want to request, for the length of time that you want to request them. Your Plan of Care should be used to plan for the entire year, and services that you expect to need at any point during that year. If you expect to need services for the entire year, your Care Coordinator will assure that the plan requests those services for the entire year.
- You must have a signed Plan of Care in order to receive services through the Innovations Waiver. That means that you need to sign a Plan containing the level of services that you want to request, which may be different than the level of services that will be approved. Your Care Coordinator will draft the Plan of Care based on your wishes, will review the plan with you before you sign it, will answer any questions you have, and will make any changes to the plan that you request before you are asked to sign it.
- If you wish to change or add services during the plan year, you may ask your Care Coordinator to help you request the change by writing an update to your Plan of Care at any time.
- You (or your legally responsible representative) will need to sign the Plan of Care once it is complete. You will not be asked to sign a plan that does not contain the level of services that you want to request. If you expect to need those services all year, you will not be asked to sign a plan that does not request those services for the entire plan year.
- The Utilization Management Department of Sandhills Center will determine whether or not the services you request are medically necessary, not your Care Coordinator. A decision on your request for services in your Pan of Care will be made within 15 days unless more information is needed.
- If any service requested in your Plan of Care is not fully approved (for example, a service is denied or is approved for fewer hours or for a length of time that is less than what you requested), you will receive a written explanation of that decision and information about how you can appeal.
- Sandhills Center will not retaliate against you in any way if you appeal. Your Care Coordinator can assist you with the forms needed to file an appeal.
- If some services are approved and some are denied, you can receive the services that were approved while you appeal the services that were denied. You may also make a new request for different services while your appeal is pending, if you wish to do so.
- Your Plan of Care will include information on the period of time for which services are requested. If services that have been requested in your Plan have been approved and then are later reduced, suspended, or terminated before the approval period has ended, and you appeal that decision, you may be able to continue to receive services during an appeal. You will receive written notice about that process before any services are reduced, suspended or terminated.