A Foot in Both Worlds: A Case Manager's Story

Over the past two decades, the landscape of senior services has transformed in response to the evolving needs of the older population, tightening budgets, and demographic changes. I am fortunate to have had the opportunity to provide care coordination services to older adults in two different, exceptional programs that continue today. There is some variability in the programs' intent and structure, but they have common goals to support elders in the community to live independently, while working to attain the highest quality of life in a cost-effective manner. My first professional case management experience was coordinating home-and community-based services for the Council on Aging of Southwestern Ohio, one of twelve area agencies on aging in the state. The case manager work was done through the Elderly Services Program (ESP), which was funded through a county property tax levy that generated approximately $24 million annually to support in-home services. Additional funding for this program came from clients' co-payments that were based upon a sliding scale fee structure. Some of the services available through the levy-funded program-homemaking, home-delivered meals, adult day services, lifeline, senior companion, home repair or modification, and respite-are only accessible in many communities through a waiver program or private payment. Other available services are those typically provided through state plan Medicaid benefits, such as personal care, medical transportation, and medical equipment. Eligible clients are sixty years of age or older, with an impairment in activities of daily living and considered ineligible for other programs that offered these services. There is no financial eligibility threshold, though case managers complete a financial assessment to determine whether a client co-payment is applicable. The other care coordination position is in a nonprofit managed care organization (MCO) in Minnesota's integrated program for older adults, the Minnesota Senior Health Options (MSHO) program. MSHO is a statewide program available to Minnesota residents ages 65 and older who are eligible for both Medicaid and Medicare. Minnesota's Department of Human Services contracts with nonprofit MCOs and county-based purchasing organizations to administer the MSHO program through a Medicare Advantage platform, allowing for the integration of Medicare, Medicaid, and Elderly Waiver benefits. The funding integrates Medicare Advantage payment, state plan Medicaid, and Elderly Waiver funding through capitated payments. Because MSHO includes both Medicaid and Medicare benefits, both the Minnesota Department of Human Services and Centers for Medicare & Medicaid Services (CMS) serve as program regulators. In addition to having their own care coordination staff, the MCO also contracted with county social services and-or public health departments, care systems, and community agencies to provide care coordination. Because MSHO integrates Medicare, Medicaid, Elderly Waiver, and supplemental MCO benefits, members have access to a rich set of benefits. Care coordinators follow members along the continuum of care and are able to modify their care plan, using the integrated benefit set to meet each member's changing needs. This program structure affords the care coordinator flexibility to authorize services beyond the usual requirements that Medicaid and Medicare impose. For instance, an MSHO member can be admitted into a Transitional Care Unit for rehabilitation without the three-day stay traditionally required by Medicare. Members who meet requirements for Minnesota's nursing facility level of care can access the Elderly Waiver benefits, and some members who do not meet these criteria may still have access to the Elderly Waiver services through an MCO benefit exception process to support creative care planning. Additional supplemental MCO benefits offered include enhanced podiatry care, nutritional benefits, health coaching, tobacco cessation programs, free gym membership with an older-adult-focused exercise program, and disease management programs.