Community Case Management: An approach to Service Coordination for Medically Complex Individuals

Navigating and accessing community based services and supports can be challenging for medically complex individuals and their caregivers.  Many experience service delivery systems that are fragmented and driven by complicated processes and rules.  As health care organizations move to create person-centered systems of care, there are a number of best practices they should keep in mind.  Many of these best practices are evidenced in the service coordination model provided by Community Case Management (CCM), a Massachusetts Medicaid (MassHealth) program.  This innovative program was designed to be a single point of entry for individuals receiving multiple Medicaid funded, home and community-based services such as in-home continuous skilled nursing (CSN) services, non-nursing supports (such as Personal Care Attendant (PCA) services), home therapies, durable medical equipment, and medical supplies.  Through a multi-disciplinary team model, individuals and their caregivers not only have streamlined access to necessary services preventing hospitalization and institutionalization but they also have the necessary supports and resources assisting them with the complexities of managing multiple care providers.   In this presentation, attendees will learn about the CCM eligibility process, review demographic, population and programmatic characteristics, and become familiar with the service coordination activities available to enrollees.