Care coordination is a central feature of programs aimed at integrating care for people who are dually eligible for Medicare and Medicaid, yet it can be challenging for health plans and providers to successfully provide care coordination. Individuals dually eligible for Medicare and Medicaid often have multiple health care, behavioral health, and social service needs. These diverse and complex needs highlight the importance of health plan care coordination. Effective care coordination includes assessing an individual’s range of needs, incorporating those needs as well as individual preferences and goals into person-centered care plans, and sharing information across all needed medical and non-medical providers and supports, including family and other caregivers.1
This blog post highlights the use of interdisciplinary teams and cross-departmental collaboration as an effective approach to enhancing care coordination. Health plans that serve dually eligible members have identified these collaborative strategies as contributing to effective care coordination.
Interdisciplinary Care Teams
An Interdisciplinary Team (IDT) brings together the knowledge and specialties from different health care disciplines to help participants receive the care they need. For example, in the Disability Competent Care (DCC) model, the core members of the IDT generally include a primary care physician, a care coordinator, a nurse, a social worker, and a behavioral health specialist. Other health care providers, such as rehabilitation specialists, durable medical equipment (DME) specialists, and hospitalists, may also be included, as needed. These team members bring an understanding of the member’s specific capabilities and knowledge about accommodations to meet their needs. As members of the IDT, these multidisciplinary providers are then responsible, individually and collectively, for the participant’s care. Responsibilities of the IDT include addressing urgent and acute episodes of care, proactively managing emerging needs, tailoring services and supports, and managing care transitions.2
Several health plans participating in the RIC Integrated Care Community of Practice (ICCoP) on Care Coordination identified the use of IDTs as a way to effectively enhance their care coordination efforts. Some plans encourage their care coordinators to collaborate with providers regarding a member’s social determinants of health and medical or long-term care assessments. This team-based approach to care plan development allows for providers to have a better understanding of external factors members face that contribute to their health overall.
One plan conducts bi-weekly meetings with clinical managers, medical directors, managers, and other stakeholders, conducting root cause analyses to identify gaps in care and proposing process improvements. The team updates existing reference guides and standard operating procedures to address any organizational gaps. This health plan also uses a data analytics platform to integrate various electronic data sources storing medical, service, and care coordination data from the plan and providers. This interdisciplinary approach to data allows care coordinators to more easily identify what care and supports have been provided and to tailor care coordination interventions for each member.
Cross-Departmental Training and Role Clarity
Other plans emphasize the importance of cross-departmental communication and collaboration for effective care coordination. One plan recommends strengthening cross-departmental training to ensure that all plan staff are aware of the different programs and services that are available for dually eligible individuals. This training features standard operating procedures and reference guides that describe the plan’s care coordination strategy and clearly outline the roles of each member of the interdisciplinary team.
Coordinating care requires a team approach and training staff in teamwork strategies may help health plans better integrate care. Creating psychological safety for team members to speak up, providing role clarity and clear expectations of accountability, and engaging members and families in development of care plans all contribute to improved care coordination.3
One health plan participating in the RIC ICCoP conducts cross-departmental, interdisciplinary morning huddles to assess member needs and triage resources for the day. The team can then prioritize and coordinate their efforts. For example, if huddle participants share that a member has an immediate need, a community-based nurse can be deployed to the member’s home to address that need.
To build on the foundations of Care Coordination presented here, a future blog post in the series will highlight the specific functions of an existing health plan’s community care plans and partnerships with hospitals. The post will also provide concrete examples of care coordination strategies that readers can reference.
Topic Summary: Interdisciplinary Team Building, Management and Communication. Resources for Integrated Care
Disability Competent Care Resource on Care Coordination. Resources for Integrated Care
1Barth, S., Silow-Carroll, S., Reagan, E., Russell, M. & Simmons, T. (2019). Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches. Health Management Associates. Retrieved from http://www.macpac.gov/wp-content/uploads/2019/03/Care-Coordination-in-Integrated-Care-Programs-Serving-Dually-Eligible-Beneficiaries.pdf.
2Resources for Integrated Care. (2019). Interdisciplinary Team Building, Management, and Communication. Retrieved from https://www.resourcesforintegratedcare.com/wp-content/uploads/2019/06/DCC_Topic_Summary_IDT_Bulding_Managment_and_Communication.pdf.
3Gandhi, T. Press Ganey Blog: Healthcare Experience Insights. (2022). Caregiver Crisis: How to Confront Challenges to Coordinated Care. Retrieved from https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/caregiver-crisis-how-to-confront-challenges-to-coordinated-care.