Coordinated management will mean better care for COA clients

Tuesday, April 22, 2014

Council on Aging’ is making dramatic changes to the way we deliver care management services to older adults and people with disabilities. The result will be the ability to offer clients enhanced services and timely support.

Under a new process for care management delivery, clients will receive care coordination through an Integrated Coordinated Care (ICC) team, rather than through a single care manager.

The new model increases the amount of time care managers are able spend working directly with clients by delegating non-clinical activities to other means of the team, , according to Ken Wilson, Director of Program Operations.

“The goal is to be more effective, less expensive, utilize our staff to their fullest potential and most importantly, provide better customer service,” he said.

COA Hands ICC Care

Benefits to clients include:

  • Designated roles for team members to ensure that each service is delivered by someone who specializes in that particular function
  • More time for clinical staff to focus on serving their clients face-to-face
  • Each member of an ICC team having knowledge of the needs and services of every client assigned to the team
  • A simplified process for clients to contact COA. Each team is assigned a single phone number and email address to be staffed by Care Coordination Specialists.

Kim Clark, Council on Aging Elderly Services Program and Assisted Living Manager, has led the development of the ICC teams and the transition to coordinated care. She said the streamlined contact process is a highlight of the ICC format. It means clients will be able to contact COA at any time during regular business hours rather than trying to reach an individual care manager who might be unavailable for an extended period while visiting homes of other clients.

According to Wilson, the new format is unique to community-based care, but similar plans have proven effective for services such as hospice care and patient-centered medical homes. Wilson and his staff worked closely with Council on Aging’s medical advisor, Douglas Smucker, MD to define the ICC teams and the role each member will serve. The eight members of each team will be:

  • Three Care Coordinators responsible for home visits and assessments to determine level of care
  • A Medical Care Coordinator who will also make assessments, concentrating on cases with complex health care needs
  • Two Community Health Specialists who will visit clients regularly to ensure they are receiving the necessary care and services
  • Three Care Coordination Specialists who will respond to calls and questions 
  • Two ICC teams have already begun serving some of the clients on the PASSPORT and Assisted Living programs. Clients are assigned to teams based on geographic and program criteria. Clark said the short term goal is to roll the coordinated care format out to all PASSPORT and Assisted Living clients and ultimately apply the format to all of COA’s care management services.