Care Coordinators Guide



Care Coordinators Guide to Reducing Community Well (non -EW) Refusals of Health Risk AssessmentsPrior to the call for an assessment: Familiarize yourself with the member. Reviewing the below resources/tips may guide your conversation with the member. Send out a welcome letter with your business card/contact information prior to calling so that the member is familiar with your name and Care Coordination services. If available, review previous assessments and care plans; LTCC, PCA supplemental assessment, 3428H, Transitional HRA, etc.Review Bridgeview: Previous assessments history, PCP and additional contact information for Guardian or Resp. Party.Review Member360: medications, authorizations, diagnosis codes.Schedule your contact to allow for enough time to complete an assessment over the phone if the member refuses to complete a face-to-face assessment. *Have forms and resources available ahead of time. This will allow you to quickly pivot and offer a telephonic assessment. Establishing your role as the health plan care coordinator: Ask the member how they would like to be addressed. Members from different cultures, generations and gender identities may have certain expectations about how to address one another. Inform the member that you are in their community and not based out of the Twin Cities from BCBS corporate office. Connect with the member. Start an informal conversation first to build rapport before talking about assessment options. Conversation starters:Give them background on why you are calling them.“You recently became eligible for Medicare and are on MA, which allows you to enroll in a managed care and your plan is Blue Cross. This may have been done with your financial worker at the county.State the member’s financial workers name, if known.Explain that one of their Blue Plus benefits is having an assigned Care Coordinator to help navigate and coordinate their health care.“I would like to discuss what I do for Blue Cross and working with people 65 and over.” (This gives a basis that the Care coordinator is specific to the over 65 population).Discuss that they may have received information from Blue Plus that you can assist with. “You may have recently received a lot of information from Blue Plus and I am willing to go over that information with you. We can discuss some of the benefits that you qualify for.” (MSHO members) In your packet you should have received information about MSHO Supplemental Benefits for this year. We can go over what those are.(MSC+ members) Discuss the Supplemental benefits and the ability to connect with our MSHO specialist.Asking for an in-home face-to-face visit: Ask for, and encourage, a face-to-face assessment.Provide a brief explanation and purpose of the HRA and care plan:The HRA assessment identifies current and future health and safety risks. The goal is to be proactive in supporting the member’s needs.The member driven care plan summarizes supports, strengths, assessed needs, risks, goals and interventions that take into consideration the member’s choice and preferences. “The assessment is for your benefit as you may qualify for services that help you and/or your caregivers to ensure you remain in your home/current living arrangement safely and as independently as possible.”“I would love to meet with you and bring you some resources. You are welcome to come to me or I can come to you. We can then complete an assessment.”Some other suggestions are meeting in a central location such as McDonalds, a coffee shop, or a library. Some members may refuse a face-to-face assessment as they do not want people in their home and are more comfortable in a central location. (Reminder: this document is only for Community Well members).Asking for a telephonic visit:If the member declines a face to face, inform the member that the assessment can be completed over the phone, and this is a shorten version of the assessment. (Telephonic HRA’s can not be used to determine EW eligibility or PCA services, Care coordinators must complete a full assessment.)If member agrees to a telephonic assessment but does not have time to complete during the initial call, then set up a time that works best for the member, and you, to complete the telephonic assessment.If, during the telephonic assessment, there are some needs that are identified, then inform the member a full assessment is available if they want assistance with the needs identified.If the member refuses both Face to Face and Telephonic assessments:Inform the member that you will give them some time to think about what was said and review the documents that were sent to them from Blue Cross. Then offer to call them back in about a week to see if there are any questions etc.“I am here to help you, is this a good time? if you do not have time right now, when would be a good time to call you back?”When calling back after a week, offer a face-to-face assessment again. If they decline offer the telephonic assessment.If a member, that has refused an assessment in the past, calls you for any reason, or during TOC activities following a hospital stay, ask to complete an assessment. Contact requirement for members who decline an assessment:Care Coordinators are required every 6 months to reach out to members to offer an assessment if they have previously been refusals or UTR. It may be helpful, prior to calling, to send out a letter with supplemental benefits (MSHO members) and your business card reminding them who you are and what you can offer.Open-ended Questions:Ask open ended questions to actively engage the member in the assessment process. Open ended questions can be used in the introduction stage, explaining the HRA purpose and throughout the assessment. ClosedOpenWould you like to complete a health Risk assessment?I would like to ask you some questions to help me better understand your interests and needs and how this assessment might be able to support you in achieving your goals. Do you know what kind of assistance you need?Talk to me about your interests and needs.Do you need any assistance ?Where do you go for assistance with any needs you have? Or you can be specific. Who helps you with…Do you need any resources?What can I do to help you find/access resources that you may need? Your plan has many great resources available to you and I would like to tell you more about those. How might xyz (specific supplemental benefits) be able to assist you? Open Ended Question TIPS:What would happen if…….?Why do you think…….?How did you……?What happened when…...?What else can you do with……?How might you use……?I wonder if……?General Tips: Before and during assessment:Be flexible with scheduling. Take your time. Ask the member what resources they have in place.Give options to resources directed by member’s person-centered goals.After the member speaks:Paraphrase what was said. Stay engaged in conversation.Stay on target and redirect the member back to topic at hand when necessary.Ask a different question if the member is struggling with a question.Inquire with clarifying questions/paraphrasing. So, you feel……It sounds like you……You are wondering if….This is what I am hearing, please correct me if I am wrong….Let me make sure I understand……You are wondering if….It sounds like you have really thought a lot about this and have some good ideas about how you might……….That is a good suggestion that you have.I appreciate that you were willing to share that with me.Establishing a rapport with members when they are healthy will open the door for when they may need assistance. ................
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