NY Manual
SHP Manual

SHP Provider Manual
3.1 Care Management | 3.2a Sample Service Plan Letter (Page 1)

3.2 Coordination of Services

Senior Health Partners provides and coordinates services designed to keep members living in their own homes for as long as possible. Senior Health Partners does this by providing a comprehensive team approach in the delivery of long-term care services. The Care Management Team (CMT)—a nurse, social worker and service coordinator—is responsible for coordinating the Medicaid and Medicare services needed by members. Every member has their own CMT, and the CMT works with the member and their family/caregiver to provide an optimal and safe care plan. 

In January 2008, Senior Health Partners introduced a “Welcome Team” and in 2012 a “Transition Team” comprised of a nurse, social worker and service coordinator dedicated exclusively to facilitating newly enrolled members. Each of the following team members performs a valuable and integrated service designed to introduce Senior Health Partners’ comprehensive care management: 

   •   The Welcome and Transition Team Nurse

                   o   Develops the Initial Plan of Care based on the initial needs assessment

                   o   Secures necessary home care services with providers (vendors)

                   o   Monitors change of health/service status

                   o   Contacts Primary Care Providers to coordinate service delivery

   •   The Welcome and Transition Team Social Worker 

                  o   Maintains contact with enrollee/family/caregiver prior to enrollment

                  o   Refers them to temporary community services as needed

   •   The Welcome and Transition Team Service Coordinator

                  o   Assists with telephone contacts

                  o   Arranges for commencement of initial services

The Welcome and Transition Teams provide care management and service coordination for the first month of enrollment. Newly enrolled members are subsequently transitioned to their permanent Care Management Teams for ongoing services.

The Senior Health Partners CMT coordinates the services members receive, and communicate with the doctors and other health care providers on an ongoing basis. CMTs will schedule appointments for members, provide for transportation to and from appointments, and arrange to meet members’ needs.

Senior Health Partners members develop a unique and strong relationship with their CMT while the team acts as an advocate and liaison between both providers and members. CMTs should be contacted whenever opportunities for improvement are identified. CMTs will contact provider staff when barriers are recognized and will work together to optimize care and satisfaction. In addition, each Care Management Team has a network of resources within Senior Health Partners to assist them in their role. For example, direct supervisors, provider relations coordinator, contract administrator, quality assurance supervisor are just a sample of what is available to oversee provider performance and member outcomes.

Service Authorizations

Service Authorizations are care decisions determined by the CMT with input from the member, family, physician and other persons involved in the care of the member. Service Authorizations will ensure that covered services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished subject to the following: 

    •   The services must be Medically Necessary 

    •   The services furnished must reasonably be expected to achieve their purposes 

    •   The services are authorized to maintain the member’s health and safety 

Procedures for authorizing services:

   •   Once services are approved, a member of the CMT determines the appropriate provider to contact

   •   Upon verbal acceptance of the case by a provider, the CMT member will prepare a written authorization detailing the type, frequency, amount of service duration and expected date of commencement

   •   Authorizations will be mailed or faxed to the provider to confirm approval and made available to Senior Health Partners’ claims processor

   •   Providers should initiate providing services only upon receipt of written authorization to ensure payment. Written authorizations should be received by providers within 24 hours following a verbal approval, or the next business day.