Care Management Team Orientation - Tufts Health Plan Senior Care Options Care Management Department
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Tufts Health Plan Senior Care Options
Model of Care Overview
Care Management
Team Orientation
Tufts Health Plan Senior Care Options
Care Management Department
Reviewed January 5, 2021
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Tufts Health Plan Senior Care Options
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Reviewed January 6, 2021 1
Tufts Health Plan Senior Care Options
Model of Care Overview
Why Senior Care Options?
Member Benefits, Eligibility and Resources
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Benefits of SCO
According to a Health Management Associates value
assessment of Senior Care Options (SCO) programs in 2015:
Members: Providers: Massachusetts:
• Have one insurance plan • Also have one point of • Receives key metrics and
and one insurance card contact for benefit and other data from SCO
• Have a care team claims questions programs to identify
coordinating all medical • Have access to member trends and best practices
and social services information via a • Can more easily budget
• Have no out of pocket Centralized Enrollee vs. FFS Medicaid
expenses Record • Shares in cost savings
• Receive regular updates through care management
from the Primary Care
Team
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Reviewed January 6, 2021 2
Tufts Health Plan Senior Care Options
Model of Care Overview
Who is eligible?
Individuals are eligible to enroll if they:
Are at least 65 or older
Have MassHealth Standard (Medicaid)
coverage
Also DO NOT reside in
Live within the service area an intermediate care
facility for mental
health conditions or in
a chronic or
Effective 1/1/2021, DO NOT have End Stage Renal Disease rehabilitation hospital
as an inpatient.
ESRD is no longer a (ESRD) at time of enrollment
disqualifying condition
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Population Distribution by County
% %
County Total Complex
Barnstable 8% 9%
Bristol 5% 5%
Essex 7% 6%
Hampden 1% 1%
Hampshire 0% 0%
Middlesex 31% 30%
Norfolk 11% 11%
Plymouth 11% 12%
Suffolk 21% 21%
Worcester 4% 4%
County distribution as of October 2020
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Reviewed January 6, 2021 3
Tufts Health Plan Senior Care Options
Model of Care Overview
2021 Service Area Landscape
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Description of the SNP population
Members by Level Members by Age Range
Level 1 Level 2 Level 3 65-74 75-84 85-94 95+
Level 3A Level 4 Institutional
2%
3% 15%
13%
8%
0% 46%
4%
Male
34% 37%
Average age: 77
72% Female 16 members aged 100+
Oldest member: 109
66%
October 2020
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Tufts Health Plan Senior Care Options
Model of Care Overview
Description of the SNP population
19% of
members
report
having
trouble
hearing
(22% of
complex
members)
20% of
members
report
having
trouble
with their
eyesight
Needs help Needs help Needs help Needs help Needs help Needs help (22% of
with 0-1 with 2-5 with 6+ ADL with 0-1 with 2-4 with 5+ complex
members)
ADL ADL IADL IADL IADL
Total membership Complex membership
October 2020
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The most vulnerable: Complex members
Caucasian/White
96% of Asian
members African American/Black
say they Hispanic/Latino
have No answer
American Indian or Alaska Native
someone
Native Hawaiian or other Pacific Islander
who can
help them
60% of members live with a
family member, paid caregiver 12%
or in an assisted living facility
37%
19%
35% of 5% are
members homeless or
live alone in another
30%
situation
October 2020
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Tufts Health Plan Senior Care Options
Model of Care Overview
The most vulnerable: Complex members
Top 5 primary languages How well do you How often do you need
help reading health-
English 38%
speak English? related materials?
Always
Chinese (Mandarin) 14% Not at all
Often 19%
Spanish 12% Not well
Sometimes
Well 35%
Cape Verdean Creole 6% 44% Rarely 10% 48%
Very well
Haitian Creole 6% Never
No answer 12%
9% No answer
12% 11%
Would you like the assistance of an
interpreter or the language line?
Yes – 45%
No – 55%
October 2020
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Tufts Health Plan SCO Plan Types
SCO Dual SCO Medi
• Tufts Health Plan Senior • Tufts Health Plan Senior Care
Care Options (HMO SNP) Options
• For members with both • For members with MassHealth
Medicare and MassHealth only
Providers should verify member eligibility prior to rendering services.
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Reviewed January 6, 2021 6
Tufts Health Plan Senior Care Options
Model of Care Overview
Standard benefits
• Medicare benefits:
• Inpatient hospital, outpatient hospital, skilled nursing, doctor
visits, emergency services, lab and diagnostics, skilled home
care, therapies, prescription drugs
• Medicaid (MassHealth) benefits:
• Custodial nursing care, Personal Care Attendant (PCA)
services, Home and Community-Based Services (HCBS), Over-
the-Counter (OTC) drugs (with prescription)
• Some benefits and services are based on assessment or may
need prior authorization
Benefits are the same for both THP SCO
plan options – SCO Dual and13SCO Medi
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What do SCO members pay?
SCO members pay NO
copayments, deductibles
or coinsurance!
Members also pay NO monthly
SCO plan premiums.
Please note: Members with Medicare who are enrolled in a SCO plan must continue
to pay their Medicare premiums – but in most cases MassHealth covers this cost.
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Tufts Health Plan Senior Care Options
Model of Care Overview
How will Medicare Part D affect SCO members?
SCO members should know that it is not
necessary to sign up for Medicare Part D, as
THP SCO provides drug coverage.
Also, if a THP SCO member signs up
for Medicare Part D, they will be
disenrolled from SCO.
Medicare Annual Enrollment (with additional
advertising encouraging seniors to enroll)
happens between October 15 – December 7!
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Funding and Administration
Both Medicare and Medicaid provide funding via capitation to
THP for our SCO Dual plan members, and only MassHealth
provides the funding for our SCO Medi plan members.
THP SCO works with a number of outside vendors for some
benefits:
• All dental services for THP SCO members are provided
through DentaQuest
• All preventive eye care services are provided through
EyeMed
• Part D benefits are administered by CVS/Caremark
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Tufts Health Plan Senior Care Options
Model of Care Overview
Complaints, appeals and grievances
A Tufts Health Plan SCO Member may:
• File a complaint or a grievance (including a complaint about any
of our providers) with the plan at any time regarding any aspect
of their care;
• File an Appeal with Tufts Health Plan SCO;
• File an Appeal with the MassHealth Board of Hearings;
• File an Appeal with Tufts Health Plan SCO and MassHealth Board
of Hearings simultaneously
Of any decision to deny, terminate, suspend, or reduce services.
A provider may appeal on behalf of an enrollee with the enrollee’s
written consent.
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Tufts Health Plan online resources
Tufts Health Plan SCO member Tufts Health Plan SCO provider
website: website:
https://www.tuftsmedicarepreferred.org/ https://www.tuftshealthplan.com/provider
Available on the member website: Available on the provider website:
Explanation of Coverage Provider Manual
Summary of Benefits Payment Policies
SCO Provider Lookup Medical Necessity Guidelines
SCO Formulary Search
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Tufts Health Plan Senior Care Options
Model of Care Overview
SCO Provider Network
Network, Referrals and Prior Authorization
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Specialized network expertise
THP contracts and credentials in the Service area with over:
• 1,200 primary care physicians
• 5,000 specialists
• 40 acute care hospitals
• 350 sub-acute facilities
• 15,000 individual, group, and facility providers encompassing many ancillary
services: including but not limited to clinical psychologists, Licensed Independent
Clinical Social Workers (LICSWs), and other behavioral health providers; physical
and occupational therapists and speech pathologists; durable medical equipment
providers; chiropractic service providers; and free-standing laboratory facilities,
imaging facilities, dialysis centers, and ambulatory surgical centers
• 800 dentists
• 1,500 routine vision care providers
• ASAP for Home and Community Based Services (HCBS)
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Model of Care Overview
Referrals and authorizations
SCO members can see any provider in the Tufts Health Plan SCO
network with a valid referral.
• Reminder: Atrius, Lahey, and Steward Medical Groups do not
require referrals within their referral circles.
Members DO NOT need prior authorization to visit out-of-network
providers, but payment will not be made by Tufts Health Plan SCO,
Medicaid, or Medicare without a valid referral.
• SCO members can see any provider with a valid referral from
their PCP, and THP SCO will cover the cost of the appointment.
Inpatient Notification is required for all medical and mental health
inpatient services.
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Services NOT requiring prior authorization
• ANY emergency conditions
• Emergency behavioral health
• Urgent Care sought out of the Service Area (worldwide)
• Urgent Care under UNUSUAL/EXTRAORDINARY
circumstances
• Emergent out-of-area Renal Dialysis
• Direct-access women’s services
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Reviewed January 6, 2021 11Tufts Health Plan Senior Care Options
Model of Care Overview
SCO Drug Coverage
Prescription, Over-the-counter and Instant
Savings
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Participating pharmacies
• CVS/Caremark is the vendor for the THP SCO pharmacy and mail order
program.
• Complete listing of CVS/Caremark network pharmacies can be found in the
provider directory.
• Members can contact CVS/Caremark at http://www.caremark.com/wps/portal to
ask about a participating pharmacy.
• Participating pharmacies include: Costco, Hannaford Food & Drug,
Kmart, Market Basket, Medicine Shoppe, Osco, Price Chopper, Rite Aid,
Sam’s Club, Sav-Mor, Shop ’n Save, ShopRite, Stop & Shop, CVS in
Target, Wal-Mart, Wegman’s, Walgreens
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Model of Care Overview
Pharmacies
• Prescriptions must be authorized by a plan provider or doctor
• Must be filled at a participating CVS/Caremark provider
• Member must show their THP SCO ID card
• Mail-order is a good option for maintenance
medications such as those for heart conditions,
cholesterol, diabetes, arthritis and
high blood pressure
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SCO mail order prescriptions (Caremark)
The SCO mail order prescription option through
Caremark is administered exactly like it is for TMP.
The member is not charged for shipping costs.
Out-of-network pharmacy services require prior
authorization, so shipping charges, if any, need to
be included in the prior authorization and the
supplier knows not to bill the member.
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Model of Care Overview
Prescription requirements & restrictions
• Due to costs and safety concerns, THP has created a list of
medications that are restricted, and members are not covered for
these drugs
• May need prior authorization for certain drugs in order to be
covered, and there may be limits to the amount of the drug that
will be covered
• Any additional requirements or restrictions are listed on the
formulary
• If there is a restriction or limits, the prescriber may ask THP SCO
to make an exception
SCO Formulary Search:
https://client.formularynavigator.com/Search.aspx?siteCode=8472686892
Be sure to bookmark on your
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laptop!
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Definition of restrictions
Icon Restriction Definition
Generic Indicator This drug is available as a generic
Home Infusion Drug Home Infusion Drug – Covered under Medicare Part B
Limited Access Limited Access
Non-extended Day’s Supply Drug This drug is limited to up to a 30-day supply per fill
Part B Drug Covered under Medicare Part B
Prior Authorization – All members Prior Authorization is required for all members
Prior Authorization – New Starts Prior Authorization is required for members newly starting on this medication
Prior Authorization is required to determine appropriate coverage under Medicare
Prior Authorization – Part B vs Part D Part B or Part D
Quantity Limit This drug has a Quantity Limit
SP-CVS Specialty This drug is available through CVS specialty (1-800-237-2767)
Step Therapy Prior Authorization Step Therapy Prior Authorization Applies
Transplant Covered under Medicare Part B when used for a Medicare-approved transplant
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Model of Care Overview
Copayments
Like other benefits and services, SCO
members pay NO copayments,
deductibles, or coinsurance for
prescriptions and over-the-counter
drugs with a prescription!
If you have any medication questions,
reach out to the Pharmacy Team:
SPPharmacyCareManagement@tufts-health.com
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Instant Savings Card
SCO members receive a $112 allowance every three
months to use toward Medicare-approved OTC items,
such as first aid and mouth care supplies.
• Members are able to use their allowance with their
THP Instant Savings card – a debit card that is
automatically reloaded with the allowance every
This benefit is
quarter
separate from the
• This benefit does not roll over to the next OTC items covered
quarter; the member must use or lose the by MassHealth and
the additional OTC
allowance
items covered by
• Members can use the their Instant Savings card at THP (covered at $0
CVS Pharmacy, Walgreens, RiteAid, Family Dollar, with a prescription).
and Dollar General
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Model of Care Overview
DailyCare Card
SCO members receive an additional $25 allowance every three months
to use toward approved products for their daily care, including:
This benefit works the same as the Instant Savings
Card, and is administered by the same company.
Members should swipe both cards when they are
shopping, as each card covers different items.
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SCO Formulary
The SCO Formulary consists of the existing HMO individual formulary
PLUS the MassHealth Over-the-Counter Drug List and the MassHealth
Non-Drug Product List.
• SCO Formulary Search:
https://client.formularynavigator.com/Search.aspx?siteCode=8472686892
• MassHealth OTC Drug List and Non-Drug Products List:
https://masshealthdruglist.ehs.state.ma.us/MHDL/
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Model of Care Overview
SCO Model of Care
Rate Cells, Levels of Care and Care Management
Requirements
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Care Model
The care model focuses on an integrated approach to care management, including
medical, behavioral, social, and long-term needs.
A SCO member’s Primary Care Team (PCT) includes a Primary Care Provider (PCP),
and may also include a Registered Nurse Care Manager (RNCM), a Behavioral Health
Care Manager (BHCM), a Community Health Worker (CHW), a Care Coordinator, and a
Geriatric Support Services Coordinator (GSSC) from an Aging Services Access Point
(ASAP)
Based on the member’s needs, the PCT may also include a Clinical
Pharmacist/Pharmacy Technician, Nurse Practitioner and/or other health specialists
Every member has an Individualized Plan of Care (IPC) that is developed during
assessment.
The plan is updated as the member’s condition and needs change
Initial ICP and at minimum annual update mailed to Member/Caregiver and PCP
A Centralized Enrollee Record (CER), accessible to all members of the care team,
contains all activity related to the member’s care
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Model of Care Overview
Rate Cells and Levels of Care
All members are enrolled as Community Well until they are evaluated by
an Assessment Nurse or RN Care Manager, who will submit an MDS-HC
to MassHealth to determine their Rate Cell.
Members are separated into Levels of Care based on their Rate Cell to
determine the most appropriate Care Manager, services and touch point
frequency.
Complexity Non-complex Complex Institutional
Community
Rate Cell Well
AD/CMI NHC
Level Level 1 – No Level 2 –
Level 3 Level 4
of Care HCBS HCBS
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Rate Cells and Levels of Care
Reimbursement is based on rate cell –
so it is important to capture the correct rate cell
as soon as possible.
It is also important to reassign the member
to the appropriate Care Manager to ensure
the most suitable person to manage
the member’s level of complexity.
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Model of Care Overview
Touch point frequency
Level 1 Level 2
Level 3 Level 4
Community Community Institutional
AD/CMI NHC
Well Well w/HCBS
Welcome Letter
Calls/Letters Welcome Call made during first 30 days by Customer Relations sent within first
30 days by CR
Initial
Initial face-to-face assessment completed within 30 days by RNCM/Assessment Nurse
Assessments
• Face-to-face • Face-to-face
• Face-to-face • Due every 90 days • Due every 90 days
• Telephonic • In-facility
• Due every • Completed by BHCM or • Completed by RNCM/NP
• Due every • Due every 90
Ongoing 180 days RNCM • 1 assessment annually
180 days days
Assessments • Completed • 1 assessment annually by GSSC or CHW
• Completed • Completed by
by GSSC or by GSSC or CHW (select members)
by GSSC CCP
CHW • Annual visit w/RNCM • Annual visit w/RNCM
required required
MDS SNF responsible
No MDS-HC MCH-HC Submitted Annually
Requirement for MDS 3.0
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PCP Contact Guidelines
At minimum…
• Initial and annual ICP mailed to PCP
• Notification of transitions of care
• Notification of changes in functional status
• Care Manager initiation of telephonic contact by the PCP
in developing the plan of care and to coordinate care (no
less than annually)
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Model of Care Overview
Disease Management Programs
The Disease Management Programs focus on five diseases:
• Diabetes
• Depression
• Dementia
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
The program includes the provision of educational materials, disease-
specific assessments, and member coaching and referrals to specialty
programs, as needed.
* Reminder: Chronic Care Improvement Program on COPD and Depression
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SCO Care Transitions
Admission and Discharge
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Model of Care Overview
Use of clinical practice guidelines and care transition protocols
THP endorses existing evidenced-based guidelines and distributes them to plan
providers via the provider website, Provider Newsletter and provider training,
including:
1. Preventive health guidelines, involving screening for disease
2. Clinical practice guidelines, outlining a recommended treatment path or use
of ancillary services
THP's clinical practice and preventive health guidelines are designed to support
preventive health, behavioral health, acute disease treatment protocols and/or
chronic disease management programs.
THP standard guidelines and practice protocols are customized for the geriatric
population.
The Care Management Team receives alerts and reminders for individual
beneficiaries if there are gaps in care per the guidelines.
Providers are expected to maintain continuity of care during transitions.
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Who’s who in Transitions of Care (TOC)
Clinical Administrative Staff – Office-based Care
Coordinators and Admins supporting field-based staff
Care Manager (CM) – GSSC, BHCM or RNCM supporting
members residing in the community
Clinical Nurse Liaison (CNL) – THP Senior Products RN
embedded within an inpatient facility
Community Care Partner (CCP) – THP Senior Products
RN embedded within a long-term care facility
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Model of Care Overview
Planned TOC – Before
Clinical Administrative Staff:
• Tasks the assigned Care Manager via CaseTrakker to advise of the
upcoming admission
• Calls the inpatient facility on the scheduled admission date to confirm the
member has been admitted
• If the admission was rescheduled or cancelled, updates CaseTrakker to
reflect the change, including a new admission date (if applicable)
Care Manager:
• Reaches out to the member and/or caregiver as their main point of contact
and support during this transition
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Planned/Unplanned TOC – During Intake/Stay
Clinical Administrative Staff:
• Requests clinical information from the facility
• Ensures that the facility has the member’s PCP contact information, and
requests they make contact
• For unplanned admissions: Sends information about the member’s ICP to
the facility
Care Manager:
• Contacts the member’s caregiver within 1 business day of admission to
discuss the care transition process, confirm changes to the member’s
status, and offer support as a single point of contact during the transition
• Notifies HCBS providers to suspend services during admission
For mental health/substance abuse admissions:
The BHCM or a member of the BH Utilization Management
(UM) team will work directly with
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Model of Care Overview
Planned/Unplanned TOC – During Intake/Stay
Clinical Nurse Liaison:
• Monitors progress during the inpatient stay, both with the member and the
facility
• Collaborates with the CM for discharge coordination if the member is
expected to return to the community, or with the CCP if the member is
expected to discharge to a long-term care facility, beginning to plan at the
time of admission
• Confirms the facility has been in
contact with the member’s PCP and
facilitates information sharing
• Updates Inpatient Stay in
CaseTrakker regularly during
admission
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TOC – Discharging to Community
Clinical Nurse Liaison:
• Updates CTD with discharge date, which triggers PHA-2 to be assigned to
Primary Owner (CM)
• Obtains Discharge Summary, if available, and sends to PCP
• If not available, Tasks Clinical Administrative Staff
Care Manager:
• Communicates discharge plan with member and/or caregiver
• Reviews and updates the ICP
• Arranges for HCBS to resume, and orders new services as needed
• Convenes ICT/PCT meeting, if needed, and documents notes and follow-up
in CaseTrakker
• Shares ICP with the Home Care Agency, if applicable, and ensures they
receive Discharge Summary from the facility
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Model of Care Overview
TOC – Discharging to Community
Care Manager:
• Completes PHA-2 with member and/or caregiver to:
• Assess member’s health status and update ICP
• Ensures that PCP/Specialist follow-up appointment is scheduled, and assist with
scheduling if it is not
• If member is at high risk for readmission: Communicates with PCP; Create
action plan/crisis plan with member/caregiver; Update ICP accordingly; Consider
referral to clinical programs/NP
• Completes or assigns the PHA-7 to be completed with member/caregiver
to:
• Reassess member’s health status and update ICP
• Ensure that PCP/Specialist follow-up appointment is scheduled or completed,
and assist with scheduling if it is not
• Ensure all member’s needs are being adequately met
• Complete medication review and reconciliation
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TOC – Discharging to Custodial Nursing
Clinical Nurse Liaison:
• Updates CaseTrakker with discharge information from inpatient facility
• Communicates with PCP/CCP and updates ICP
Continuing Care Partner:
• Coordinates with the CNL/custodial nursing facility about member’s health
status, risk for admission and care plan on an ongoing basis
• Continues to outreach to member and/or custodial nursing facility for
ongoing assessments and ICP updates
Care Manager:
• Reaches out to the member and/or caregiver as their main point of contact
and support during this transition
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Model of Care Overview
SCO Primary Care Team
Roles and Responsibilities
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Care coordination
Staff supporting the program, including care management roles
and responsibilities:
• Clinical Manager • Geriatric Support Services
• Assessment Nurse Coordinator
• Nurse Care Manager • Community Health Worker
• Nurse Practitioner • Care Coordinator
• 24/7 On-Call Nurse • Clinical Administrative Staff
Practitioner • Clinical Pharmacist or
• Behavioral Health Clinician Pharmacy Technician
• Dementia Consultant
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Model of Care Overview
Assessment Nurse
A registered nurse who conducts initial assessments:
• Identifies the clinical, behavioral and social needs of the member
• Develops initial Service Plan and Care Plan for new members
based on assessment results
• Initial assessments must be done face to face*
* During normal operating times
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Clinical Manager
Responsible for:
• Oversight and monitoring of care management functions and
delivery of metrics to ensure adherence to clinical quality,
compliance metrics and care model delivery
• Direct oversight and responsibility of RNCMs and/or Clinical
Consultant team
• Oversight of the clinical performance of the Aging Service Access
Points (ASAPs)
• Acts as a clinical consultant to the field-based Care Managers and
Supervisors on individual cases
• Identifies additional opportunities for growth and development of
the Clinical Team
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Model of Care Overview
RN Care Manager (RNCM)
Healthcare Professional (RN) responsible for managing care
for members with complex care needs:
• Completes initial assessments for community members as needed
• Secondary Care Manager for Level 3 members, conducting annual
assessments and assessments for change in condition
• Ongoing assessments for Level 4 members, including:
• Development and implementation of Individualized Care Plan (ICP or Care Plan)
• Key player in ICT/PCT meetings
• Initiates HCBS in collaboration with GSSC
• Care coordination and planning in collaboration with PCP
• Post-hospitalization Assessments (PHAs) and follow-through
• Disease Management Program assignment and implementation
• MDS-HC completion annually for Level 3 and 4 members
• Resource and support for BHCM, GSSC, CHW and CC staff
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Nurse Practitioner
Licensed Nurse Practitioner (NP) serving as a consultant for
high-risk members and those with complex conditions:
• Consult to ICT/PCT for all members, regardless of Level, regarding medical
conditions
• Acts a resource for the clinical teams as it relates to chronic and complex
patient management with advanced level insight and support with regards
to high chronic disease burden, decline in functional status, progressive
disease trajectories and goals of care discussions and planning
• Support and enhance the overall plan of care for our members that are
member centric and intervention based through all transitions of care
• Conduct annual comprehensive exams that help build the foundation for
short and long term care needs and establish those relationships needed
to promote health promotion and wellness
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Model of Care Overview
Advanced Practice Nurse (APN) Clinical Care Delivery Program
Members will continue to be • High risk acute inpatient admission
• Required ICU stay while in the hospital
managed by an RNCM, with an • Hospital stay > 7 days
• Poor prognosis
additional support system • High risk hospital discharge / High risk SNF discharge
• Required ICU stay while in the hospital
comprised of an interdisciplinary • Hospital stay > 7 days
• Recommended skilled stay but discharged home
team of clinicians and specialists • Significant decline and functional limitations as a result of
medical
that focus on advanced illness • New CAD/MI with poor EF/endurance, new CVA with deficits, progressive
dementia with indications of FTT requiring more and more care, etc.
management with additional • High Re-Admission rate as identified on re-admission reports
• High Re-Admission rate (> 2 in the past 2 months)
attention to progressive disease • In patient stay / not observation stays
• Multiple ED visits
trajectories and complicating social • Medication reconciliation revealed concerning medication regimen
determinants. • Alignment of progressive disease trajectories lacking with
associated poor prognosis
• Frail elder w/ multiple co-morbidities and in need of complex
The APN will support the clinical medical management
• New diagnosis of CAD w/ renal issues, diabetic on insulin with new renal
teams at any time additional input failure and dialysis, etc.
• Significant decline and functional limitations as a result of new
is sought and when the member and or end stage medical conditions
• New CAD/MI with poor EF/endurance, new CVA with deficits, progressive
meets higher risk criteria. dementia with indications of FTT requiring more and more care, etc.
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24-hour on-call nurse
Per EOHHS, SCO is required to provide members with 24/7
access to a clinical professional, which we do through our toll-
free Customer Relations line.
• Customer Relations will answer M-F between 8am-8pm, and will contact
the member’s CM if necessary
• Members may also reach out to their CM or Care Coordinator
directly during regular business hours (8am-5pm)
• After 8pm, members reach a recording where they can leave a message
for Customer Relations, or press 1 for urgent medical issues
• Senior Products NPs have a weekly rotation for after-hours calls
• Calls are documented in CaseTrakker, and follow-up Tasks assigned
as needed
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Model of Care Overview
Behavioral Health Care Managers (BHCM)
Behavioral Health Clinicians providing support and care management
for members with behavioral health needs:
• Assist with early identification and intervention of behavioral health and
substance abuse needs
• Serve as Care Manager for Level 3 members rated with Alzheimer’s
Dementia/Chronic Mental Illness (AD/CMI)
• Collaborate with RN Care Manager on coordination of care with
Department of Mental Health as needed
• Assist with referrals to behavioral health providers
• Collaborate with ICT/PCT on coordination of care for members with serious
and persistent mental illness and substance use disorders
• With RN Care Manager, co-manage Level 4 members with behavioral
health conditions
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Geriatric Support Services Coordinators (GSSC)
Community resource contracted through
Aging Services Access Point (ASAP)
Collaborates with RNCM
Can serve as Care Manager
Coordinates Home and and BHCM on care
for Community Well members
Community-Based coordination, ICP and
and perform assessments for all
Services (HCBS) Plan of Care
members
implementation
• Biannual telephonic assessments for
Level 1 members
• Biannual face-to-face assessments
for Level 2 members Assists with Medicaid
• Can perform one quarterly face-to- Participates as needed for
(MassHealth) eligibility
face assessment for Level 3 or Level ICT/PCT meetings
4 members
issues
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Model of Care Overview
Community Health Worker
Additional community support for the member, assisting CMs
in following up on member Care Plans:
• Serves as RNCM extender/support, particularly when GSSC assistance is
not available, focusing on in-home work with members to implement Care
Plan interventions as assigned by CMs
• Assists RNCM with completion of Care Plan Interventions for Complex
members residing in the community requiring assistance with ADLs
• Works collaboratively with RNCM, ICT/PCT and providers to increase
member knowledge, motivation and treatment through targeted
interventions that address the member’s holistic needs from a
psychosocial, medical and socioeconomic perspective
• Primary resource to support members experiencing loneliness/social
isolation
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Care Coordinators (CC)
Member-facing office staff supporting field-based Care
Managers:
• Responds to member phone calls and questions regarding HCBS
and Durable Medical Equipment (DME)
• Calling provider offices for clinical information, including History &
Physicals (H&Ps) and referral documentation
• Faxing clinical information to HCBS providers, including requests
for services, member Care Plans and referrals
• Scheduling assessment visits on behalf of Care Managers and
Nurse Practitioners
• Schedulers supporting Care Managers are in the process of
being embedded within SCO Area Teams
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Model of Care Overview
Clinical Administrative Staff
Office staff supporting behind-the-scenes Care Management
processes for all SCO staff:
• Coordinates intake process for new members
• Sends members in Disease Management Programs educational
materials approved by EOHHS
• Creates Outpatient Events (OPEs) to authorize HCBS on behalf of
Care Managers
• Supports Care Coordinators with administrative tasks
• May have additional projects/assignments as needed
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Clinical Pharmacist & Pharmacy Technicians
Clinical Pharmacist supervises a group of Pharmacy Techs,
embedded in the ICT/PCT, to improve quality of care through:
• Care coordination
• Medication management programs
• Consultative services
• Quality initiatives
• Comprehensive medication management reviews to improve outcomes,
reduce drug related problems and reduce admissions/readmissions
• Examples:
• Advises member and ICT/PCT on the selection, dosages, interactions and side
effects of medications
• May teach member how to administer medications
• May perform medication reconciliation and review
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Reviewed January 6, 2021 31Tufts Health Plan Senior Care Options
Model of Care Overview
Dementia Care Consultants
The Dementia Care Consultant is a THP employee who sits at
the Alzheimer's Association to support all THP
members/caregivers by:
• Providing information to members and/or caregivers to develop a
better understanding of their diagnosis and develop strategies for
symptom management
• Screening members for changes in cognitive function and
providing tools, education, support and care planning
• Coordinating care with Care Manager, family, PCP and other
members of the ICT/PCT in short-term, focused interventions
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Role of THP Customer Relations
Customer Relations:
• Acts as a enrollee service representative (ESR), working in an incoming call
center environment
• Must have access to the CER (CaseTrakker)
• Conducts Welcome Calls ESR
• Assists members if they want to file an appeal or grievance
• Assists members with billing questions
• Assists members with benefit questions
Care
• Assists members with lost ID cards Coordinator
Care Manager
• Connects with the Care Manager as needed
Per EOHHS requirements, ESRs must be available during normal business hours
on a daily basis, and must answer 90% of all calls within 20 seconds or less.
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Model of Care Overview
Role of Tufts Health Plan Provider Relations
Provider Relations: 800-279-9022
• Serves as the main point of contact for provider inquiries
• Addresses inquiries regarding covered benefits, claims and Explanations of
Payment (EOP)
• Confirms member eligibility
• Answers general and specific provider questions
Provider Education: Provider_Education@tufts-health.com
• Educates providers about products, policies and procedures and self-
service technology solutions.
• Offers educational programs in the form of webcasts, webinars and onsite
meetings
For self-service information and forms, visit the
Tufts Health Plan Provider website:
https://tuftshealthplan.com/provider
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RN Care
Manager
Primary
BH Care
Care
Manager
Provider
APN Palliative
SNF/LTC Care APN
Rounder
Member
Care Community
Coordinator APN
Clinical Dementia
Pharmacist Care
Community
& Consultant
Health GSSC
Technicians
Worker
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Reviewed January 6, 2021 33Tufts Health Plan Senior Care Options
Model of Care Overview
Individualized Plan of Care (IPC) Process
Initial assessment and IPC
Member assessed by completed by RNCM or
ICT/PCT Member Onboarding Nurse to ensure
member is assigned the
correct Level and CM
Problems identified by
IPC Letter sent to assessment are
member and PCP discussed with Initial IPC completed on
member/caregiver
carbon copy form and signed
ICP will include:
during visit by
• Problem list reviewed at each visit member/authorized
• Short and long term goals that are representative; Annual IPCs
measurable and member-centric are mailed for signature
• Interventions assigned to PCT members (with SASE)
Services requested IPC developed and
reviewed with
and put into place by member/caregiver using
Members are re-assessed
ICT/PCT feedback every 3-6 months (based on
Level), or with any change in
member’s condition
Member/Authorized
Rep signs IPC
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Questions?
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Reviewed January 6, 2021 34You can also read
