Managed Care/Behavioral Health Case Study

Client Characteristics

  • Name: Gloria Cox
  • Sex: Female
  • Age: 46
  • Diagnoses: Chronic Deep Vein Thrombosis, Type II Diabetes Mellitus, Schizoaffective Disorder
  • Date of Last Nursing Facility Admission: August 3, 2007
  • Date of Last Living Options: August 16, 2006
  • Legal Status: Legally Competent Adult
  • Current Residence: HIJ Nursing Facility, a 168 bed nursing facility located in San Antonio, Texas

Background

Gloria Cox is a 46-year-old female with a diagnosis of Schizoaffective Disorder, Bipolar type, who was on psychotropic medication since she was 20 years old. Prior to admission to a nursing facility, Ms. Cox lived with her boyfriend Milan, who had Schizophrenia for approximately 20 years. Ms. Cox relied on Milan to help her with daily activities since she began to have difficulty ambulating due to chronic deep vein thrombosis in both of her legs, and Type II diabetes mellitus. Milan also assisted her by doing laundry, grocery shopping, housekeeping and cooking.

Ms. Cox required insulin injections twice a day and took other medications, but needed assistance with her daily insulin injections as well as filling her pillbox each week. §Ms. Cox required some assistance transferring to and from bed, or bath, to her walker and assistance with appropriate toileting. She was able to bathe, feed and groom herself with prompting, although she often dressed inappropriately before entering the nursing facility (e.g., wore several shirts or dresses at once, wore a parka in hot weather, wore stained or unwashed clothing). Ms. Cox also needed assistance dressing herself and in particular putting on shoes.

Ms. Cox was placed in the nursing facility by her mental health caseworker and Adult Protective Services after Milan was admitted to the psychiatric hospital approximately eight months ago. She had bouts of depressed mood that was intensified with her inability to ambulate well. Ms. Cox had no family members or friends who remained involved in her life, other than Milan, who came to visit her at the nursing facility once a week. Milan attended church regularly and attempted to get Ms. Cox to go with him, but she refused to go saying that she was uncomfortable around crowds. Ms. Cox also had a history of self-medicating with alcohol and street drugs before entering the nursing facility.

DADS uses Minimum Data Set 2.0 (MDS) data to help determine who might want to transition from a nursing facility back into the community. Item Q1A of Ms. Cox—s initial MDS screen indicated that she wanted to leave the nursing facility to live in the community and also indicated that she had prior behavioral health issues.

top of page

Learning About Community Options

The MDS data is transmitted to the local relocation contractor which triggers a visit by the relocation specialist. The relocation specialist verified that Ms. Cox wanted to move back into the community, and that she had a prior history of mental health and substance abuse issues. Ms. Cox indicated that her goal was to live with Milan again some day, but feared that he could be hospitalized again, thus causing her to return to the nursing facility.§ Ms. Cox also indicated that she wanted Milan involved in her life, and wanted him to take part in helping her with her decisions about the move.

After the visit, the relocation specialist obtained her informed consent and referred Ms. Cox to the local DADS Star+PLUS Support Unit (SPSU) to begin her relocation to community services (see Glossary). The SPSU was contacted rather than a DADS case manager because San Antonio is in a managed care catchment area where long term services and supports are provided through the Star+PLUS Medicaid 1915(c) waiver.

Ms. Cox was informed that Star+PLUS is a Texas Medicaid managed care program designed to provide health care, acute and long-term services and support through a managed care system. The 1915(c) waiver program provides a continuum of care with a range of options and flexibility to meet individual needs. The program increases the number and types of providers available to Medicaid clients.

Participants of Star+PLUS select a managed care organization (MCO) from those available in their county, and receive Medicaid services through the managed care health plan. Through these managed care health plans, the Star+PLUS program combines traditional health care (such as doctor visits) and long-term services and support, such as providing help in the individual—s home with daily activities, home modifications, respite care (short-term supervision) and personal assistance.

Service coordination is a main feature of Star+PLUS. Medicaid clients, their family and providers work together to help clients coordinate health, long-term and other community support services. 

top of page

Choosing a Service Provider

The SPSU provided Ms. Cox with information so that she could select a Star+PLUS MCO. Concurrently, the relocation specialist assisted Ms. Cox in transitioning her Supplemental Security Income (SSI) benefits to the community setting. She chose a MCO who assigned a service coordinator who assisted her in developing a service plan.

The service coordinator also convened a staffing by the transition team. The transition team included representatives from: Ms. Cox, the local mental health authority, the relocation contractor, the Organization for Screening, Assessment and Referral (OSAR — the substance abuse services provider), the public housing agency and local advocates. The transition team helped to initiate all the supporting activities to make Ms. Cox—s relocation to the community a reality.

The service coordinator visited Ms. Cox in order to have assessed her needs, and discuss the types of home and community-based services that were available. Shortly after the assessment, the service coordinator and Ms. Cox agreed on her individual plan of care. The plan included peer support, home and community-based 1915(c) waiver services through the Star+PLUS 1915(c) waiver program, Cognitive Adaptation Training (CAT) and screening/assessment for substance abuse services through the OSAR.

The CAT services were selected because of the unique behavioral health needs of Ms. Cox. CAT services are rehabilitation services that address the cognitive deficits of the individual, and assist the person to establish their environment and provide tools to support skill acquisition including improvement in medication adherence, personal care and activities of daily living, social skills, and integration into the community.

The service coordinator also discussed the three types of consumer directed service options available to Ms. Cox (see discussion under the Nursing Facility Case Study). Ms. Cox did not feel she was ready to select consumer directed services but wanted to reconsider the option at a later date

While Ms. Cox wanted to move back with Milan, who was now living in the community again, she realized that to increase the success of the transition that she would need support in maintaining her sobriety and independence. After discussing possible living arrangements with the relocation specialist, she chose to live in a licensed adult foster care home until she is ready to live in an apartment of her own with Milan.§ Ms. Cox visited the foster home where the foster care provider explained where she was to sleep, the types of activities available and the meal options such as joining the family in the dining room or eating her meal in her room. Ms. Cox indicated that she was pleased with the living arrangement, the foster family and the family pets.

top of page

Post Transition

As part of her individual plan, Ms. Cox received personal care assistance, adaptive aids, physical health care and counseling through Star+PLUS. Ms. Cox was assisted in locating a local pharmacy that delivers medication. Her service coordinator helped her arrange for dental services through the local Health District, assisted Ms. Cox in completing an application to a local transportation provider in order to receive transportation to and from her medical appointments, and assisted her in learning how to use the public transportation system to attend a support group for individuals recovering from addiction. She also received CAT from the CAT provider to assist her in organizing her environment and learning to perform daily activities, such as how to do her own laundry, dressing appropriately for the season, and managing her medications.

The CAT provider worked closely with Ms. Cox—s personal care provider to ensure that cognitive adaptation is understood and supported by her personal care attendants. The relocation specialist helped Ms. Cox understand how to work with the members of her support team and to advocate for herself. The service coordinator ensured that Ms. Cox—s continued to receive the health, long-term services and supports, and behavioral health services she required.

After training and assistance from the CAT provider, Ms. Cox was ready to move from the group home setting to her own apartment. The relocation specialist monitored Ms. Cox—s progress over the training period and when she was ready to move, identified suitable, accessible and subsidized housing for Ms. Cox—s consideration. Ms. Cox decided at this time to live with Milan, so they were shown three available apartments and they selected a furnished apartment which was closer to a grocery store and her physician—s office. The relocation specialist assisted Ms. Cox in relocating, and visits her and Milan periodically to ensure that they are getting along well.

Ms. Cox continued to receive her acute and long term services and supports through the Star+PLUS program, and once she was settled and functioning on a day to day basis in her new home, Ms. Cox began receiving psychosocial rehabilitative services through the local mental health authority to help maintain and further her independence.

Ms. Cox—s Star+PLUS service coordinator periodically monitors her situation to ensure that she is receiving the health and long term care services described in her plan of care and that these services are working for her. When changes are required, or once every 12 months (whichever is less) the Star+PLUS service coordinator revises the plan of care, with the active involvement of Ms. Cox, her providers and Milan, to reflect Ms Cox—s evolving needs and preferences. The local mental health provider reviews and updates Ms. Cox—s psychosocial rehabilitation plan every 90 days, coordinating their activities and services with the individual plan developed by the Star+PLUS service coordinator. Finally, the relocation specialist visits Ms. Cox periodically both in person and by telephone. Ms. Cox is provided with phone numbers for each of these organizations/individuals and told what to do in an emergency.

top of page

Loss of Medical Necessity

Ms. Cox significantly improved during the Demonstration period as the result of better coordinated care through the managed care organization and being the recipient of CAT services. Ms. Cox became a compliant individual and took her medications in a timely manner. Both her behavioral and medical health improved to such a degree that upon her annual reassessment, as she prepared to transition from the Demonstration to regular STAR+PLUS services, she was denied medical necessity (MN). The decision to deny MN was appealed to a Fair Hearing judge who upheld the decision.

The STAR+PLUS service coordinator worked with Ms. Cox and Milan, and evaluated her for attendant services. Ms. Cox met the functional eligibility criteria for that service, and the service coordinator worked with her and the attendant care provider agency to develop a service plan. It was determined that Ms. Cox would receive fifteen hours per week of attendant services. The consumer directed services (CDS) option was offered but declined. Ms. Cox continues to receive her acute care services through STAR+PLUS, while the local mental health provider continues to review and updates her psychosocial rehabilitation plan every ninety days coordinating activities with the managed care service coordinator.

Ms. Cox is thriving in the community and increasingly is becoming more engaged in social interactions. She is considering re-entering the workforce and has requested information about Texas— Medicaid Buy-In program, and has contacted the Texas Department of Assistive and Rehabilitative Services about vocational training.

top of page

Updated: May 1, 2015