Post on 07-Apr-2017
Commonwealth Coordinated Care Program and Long Term Services and Supports Across the Lifespan
Virginia Governor’s Conference on Aging Tom Wilfong, VP, Dual Eligible Programs
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• Key to serving older adults and people with disabilities is high quality, integrated, culturally-competent service coordination for the member needing long term services and supports
• 90 percent of Anthem members surveyed state that they expect to remain in their homes, yet over 65 percent need assistance with ADLs - bathing, dressing, walking, or grooming
• Almost half need assistance with IADLs - banking, grocery shopping, managing housework and errands
Experience + Expertise
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Expand Key Partnerships
Standard • Members
and Families
• Health Plan
Expanded • AAAs and
ADRCs • Faith-
based
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Coordination isIntegration and coordination of physical health, mental health and substance use disorders with long term services and supports in the community
• Holistic approach and Member engagement are key • Access to all LTSS services through a single program,
including self-direction • Access to Coordination Support Team for individuals
with more intensive needs • Members have direct access to case managers for
individualized support needs
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Aging = TransitionsPeriodically, members may need in-patient clinical care or rehabilitation.
These experiences should not mean permanent placement which results in loss of home or total loss of independence.
A good long term services and support system means
• Preserving the ability to live in one’s own home or preferred setting in the community
• Access to wide variety of options with varying levels of support to meet emerging needs
• Flexibility and focus to transition from facility-based care to support in home and community
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Landscape of TransitionsAging is not static – members may experience a variety of transitions
• From their own home to a family member's home • From their family home to a smaller home or apartment where space is
more manageable • From a nursing facility after an health incident to home or from home to a
facility for rehab • From a hospital to home following a health incident • Support for end of life planning
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Care TransitionsKey elements of coordination during transitions: • Member’s individual plan is central • Transition planning includes family, neighbors, other care
givers as a team with the clinicians • Caregiver capacity is assessed and supported • Exchange of critical information and training for care tasks
is providing in accessible manner • Warm transfers / and check - ins • Immediate access to coordinator / manager • On-going support
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Questions?