Community Care Plans – Spotlight on My Choice Wisconsin

Date: April 24, 2023
Time to read: 7 minutes.

My Choice Wisconsin (MCW) is a non-profit managed care organization with demonstrated success working collaboratively with local agencies and healthcare providers. The health plan provides two plans for people dually eligible for Medicare and Medicaid: a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) and a Dual Eligible Special Needs Plan (D-SNP). In addition to an array of inclusive health plan offerings, MCW emphasizes care coordination and a commitment to fostering partnerships to promote more integrated care. The plan strives to uphold its core values of service, equity, respect, vision, and empowerment.1

Fostering Partnerships

MCW leadership identified an opportunity to develop relationships with four larger hospital systems to collaborate and address ongoing care coordination concerns after receiving several calls to health plan care management about member-specific questions or challenges. MCW took the opportunity to request standing meetings with the hospital systems’ directors of social work or care coordination. The meetings proved to be valuable and MCW expanded them to a frequency that supports both health plan and various hospital department leadership attendance, including medical directors, nurse practitioners, directors of inpatient care coordination, directors of emergency department care coordination, and directors of discharge. Additionally, two of the four large hospital systems are partners, so MCW can efficiently collaborate across both systems during a single meeting time.

MCW also leverages partnerships with local community organizations to support discharge planning to avoid hospital readmission. Organizations that MCW partners with offer care management services, skilled nursing care, supportive home care, specialized medical equipment and supplies, and transportation coordination. Health plan leadership representatives are encouraged to participate in local coalition meetings, such as a local crisis stabilization task force, a dementia coalition, and adult protective services, to develop ongoing relationships with community partners and identify direct contacts at community organizations that may be contacted to resolve emergent issues.

The partnerships with hospital systems and with community organizations have successfully strengthened problem solving strategies for complex care coordination issues that appear in real-time.

Care Coordination

When new members join MCW, they are automatically assigned to a care team who supports the following:

  • Creating and updating care plans as needed, based on member preferences and changes in conditions
  • Setting health and safety goals
  • Accessing the doctors and treatments the member needs
  • Coordinating appointments
  • Accessing member benefits, including supplemental benefits
  • Connecting members to food, housing, or community resources2

In addition to these care coordination benefits, MCW employs various strategies to improve care coordination for a member following hospitalization. When a member visits the emergency department (ED) or is admitted to the hospital, the plan receives an automatic notification of admission and discharge orders via WISHIN, a health information exchange (HIE) that integrates notifications of healthcare encounters directly to MCW’s care management notification system; this allows the plan to assist with timely care coordination and care transitions. Additionally, MCW staffs registered nurses (RN) with permission and access to the HIE. This functionality allows MCW to plan transitions of care and timely transfers of patients from higher acuity to lower acuity settings to reduce hospital readmissions, and ensure solutions are not siloed within a single hospital system.

MCW emphasizes member and family engagement in discharge planning, citing it as an effective strategy to reduce avoidable readmissions and support successful care coordination. MCW prides themselves on their support surrounding care transitions; their systems ensure follow-up appointments are scheduled in a timely manner and MCW is proactive in planning for emergencies that may arise.  MCW developed comprehensive protocols for various care transitions scenarios in an effort to ensure continuity of care, member health and safety, and a collaborative communication process which engages the member and their loved ones from the day of admission.

The care transitions process begins with MCW receiving the notification of a member’s admission. From there a MCW care team RN notifies the hospital discharge planner that the individual is a member of MCW and informs them of the member’s services provided by the plan. The MCW care team RN is responsible for following the member during their hospital stay and coordinating care needs with the member or their legal decision maker, healthcare provider, and hospital personnel. This may include assistance with scheduling follow-up medical appointments, arranging in-home care services, and coordinating interventions to help reduce the likelihood or frequency of readmissions.

By leveraging MCW’s hospital system partnerships, interdisciplinary care teams (IDT) work to promote other resources to patients, such as community organizations, to provide health literacy education and culturally competent member education. MCW IDTs follow members pre- and post-discharge, often assisting with care coordination. The IDT team at MCW conducts retroactive reviews of readmissions to identify gaps and note if a readmission was related to a previous admission. Using information from these reviews helps MCW improve processes to reduce avoidable readmissions in the future.

Community Care Plans

MCW utilizes community care plans to bolster stakeholder involvement and facilitate interventions for members with complex needs and members with high ED utilization. The community care plan can be tailored to any patient and makes the IDT aware of the care plan to improve quality of care for members.

A community care plan is a formal process that identifies existing needs, recognizes a member’s potential needs or risks, and develops care plan goals to support positive health outcomes. The plan is created by a nurse practitioner and has background information about the trajectory of the member’s illness, comorbidities, the expected near- and long-term health outcomes, information about the IDT for the patient (including names and contact information), the goals that the patient has for their care going forward, and the healthcare team’s general strategies and interventions. The community care plan provides a pathway of communication between the member and other healthcare providers to achieve the desired healthcare goals, and are created in collaboration with the member, the member’s primary care physicians, and all other IDT staff that surround that member.


This is the RIC webpage dedicated to the topic of Care Transitions. RIC describes why care transitions is important to care coordination, outlines key aspects, and notes the impact on care delivery.

This is the My Choice Wisconsin health plan website where visitors and health plan members can learn more about the plan’s patient-centered structure and robust member benefits. The site includes pages dedicated to care coordination for each type of plan offered by MCW. Each page describes a care team, the care team composition, how they help members, and what happens immediately upon enrollment.

This is the My Choice Wisconsin health plan webpage on the CMS website that reports individual health plan Model of Care (MOC) scores. SNPs are required to have a MOC that is reviewed and approved by the National Committee for Quality Assurance. Health plans are assigned a score that is available to consumers. MCW’s overall score is made of up four MOC scores.

This is the WISHIN health information exchange (HIE) network webpage describing the various types of HIE services offered to support health information integration across the Wisconsin health care provider landscape.

1 Disability in Wisconsin. (n.d). My Choice Wisconsin Brochure. Retrieved from

2 My Choice Wisconsin. (2020). About Care Coordination. Retrieved from