DCS Comprehensive Health Plan

Identifying Members with Special Health Care Needs

Statement/Purpose

The Department of Child Safety Comprehensive Health Plan (DCS CHP) provides care coordination for members with special health care needs.

Definitions

Enrollment Transition Information (ETI): Member specific information the Relinquishing Contractor must complete and transmit to the Receiving Contractor or Fee-For-Service (FFS)Program for those members requiring coordination of services as a result of transitioning to another Contractor or FFS Program.

Member Transition: The process during which members change from one Contractor or Fee-For-Service (FFS) Program to another.

Special Health Care Needs (SHCN): Serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that required by members generally; that lasts or is expected to last one year or longer and may require ongoing care not generally provided by a Primary Care Provider (PCP).

Policy

Members with special health care needs are members who have serious and chronic physical, developmental or behavioral conditions, and require medically necessary health and related services of a type or amount beyond that required by members generally.

DCS CHP’s population of children in out-of-home care are children with special health care needs. DCS CHP identifies children with certain health conditions who are at high risk for care coordination as needed.

DCS CHP’s "at-risk" categories include, but are not limited to:

• Members entering out-of-home placement that are known to be under-immunized or lacking immediate medical or behavioral health services;

• Pregnant members;

• Members diagnosed with Opioid Use Disorder (OUD), including pregnant women and members with co-occurring pain and opioid use disorder;

• Members diagnosed with Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) and/or other Sexually-Transmitted Infections (STIs);

• Substance-Exposed Newborns (SEN) and infants diagnosed with Neonatal Abstinence Syndrome (NAS);

• Neonatal Intensive Care Unit (NICU) graduates;

• Members diagnosed with Serious Combined Immunodeficiency (SCID);

• Members receiving services through the Arizona Early Intervention Program (AzEIP);

• Members with disabilities requiring incontinent briefs;

• Members with significant medical or behavioral health conditions, such as asthma, diabetes, hypertension, depression, or serious mental illness, that require ongoing specialist care and appointments;

• Members with a chronic illness, which has placed the member in a high -risk category and/or resulted in emergency department utilization, hospitalization, or placement in nursing care, or other facilities;

• Members receiving chemotherapy and/or radiation or dialysis;

• Members who are transplant eligible and who are actively engaged in the transplant process for up to one-year post transplant;

• Members on a high-cost specialty drug or biologic;

• Members hospitalized at the time of transition;

• Members enrolled in the Division of Developmental Disabilities (DDD), Arizona Long Term Care Services (ALTCS) program;

• Members enrolled in Children's Rehabilitative Services (CRS);

• Members who are medically complex and/or require intensive physical and or behavioral health support services;

• Members with ongoing medical needs, such as medical equipment, home care services, ongoing need for medically necessary transportation;

• Members who need pain management services or prescription medications where they have been stabilized through a step therapy process;

• Members who have a Serious Emotionally Disturbed (SED) diagnosis flag;

• Members with a Serious Mental Illness (SMI) designation;

• Members with an assessed need that is equivalent to an Early Childhood Service Intensity Instrument/Child and Adolescent Level of Care Utilization System (ECSII/CALOCUS) score of 4, 5 or 6;

• Members with a diagnosis of autism or who are at risk for autism;

• Members identified as a High Need/High Cost member;

• Members who are covered under the EPSDT program and are receiving services that are not covered under the State Plan;

• Members with a medical condition that lasts, or is expected to last, one year or longer and/or requires ongoing care not generally provided by a Primary Care Provider (PCP); and

• Members who frequently contact AHCCCS, State and local officials, the Governor’s Office and/or the media.

All members entering the DCS CHP health plan are referred by the custodial guardian for an Integrated Rapid Response Assessment. This assessment consists of a behavioral health assessment as well as a physical health screening, to be completed within 72 hours of the referral. This process aids in the identification of immediate health care needs at the time of removal which includes special health conditions requiring ongoing care coordination. Additionally, DCS CHP’s contracted MCO conducts health risk assessments on all new members. These assessments are also instrumental in identifying children with special health care needs and referring them for the appropriate care coordination.

The DCS CHP Resource Coordination team contacts new members and conducts a brief telephonic screening for CRS conditions or other chronic health coordination and subsequent referral to care coordination.

DCS CHP collaborates with other AHCCCS health plans to transfer member information and identify care coordination, through warm handoffs and review of conditions listed on ETI forms (see DCS CHP Policy HS-CC-01, Transition of Members).

Procedure

DCS CHP and its contracted MCO reviews EPSDT forms for quality and completeness of exams. EPSDT forms are assessed for potential and actual referrals to:

• Children's Rehabilitative Services (CRS);

• Division of Developmental Disabilities (DDD);

• Arizona Long Term Care System (ALTCS);

• Arizona Early Intervention Program (AzEIP);

• Head Start; and

• Specialty services such as: cardiology, neurology, vision, dental services and all other specialties.

If referrals are identified, a notification is sent to the member’s custodial agency representative to inform them of the referral and to provide assistance if needed. Referrals are followed until the visit with the requested specialty services is completed or determined as no longer needed by the referring provider.

Children with immunization delays are identified through EPSDT and immunization reviews and outreach conducted by the DCS CHP Resource Coordination process. Immunizations are confirmed via online access to the Arizona State Immunization Information System (ASIIS), which allows viewing of current immunization status and forecasting of needed immunizations.

Members are also identified through the medical management functions of prior authorization process, concurrent review, daily review of emergency department notifications, ETI forms, and through retrospective claims review.

Care Coordination and Transition

Once identified, the member is assigned for care coordination that is specific to the risk factor or condition identified. Care Coordination staff coordinate with the custodial agency representative and caregiver to streamline the care for the member. When a member is transferring to another health plan, medical care and treatment plan information, if available, is shared with the receiving health plan via ETI forms and warm handoffs.

Coordination Meetings

DCS CHP facilitates and participates in coordination meetings on an ongoing frequency. These meetings include opportunities for discussion of member needs thereby further identifying members with special healthcare needs that require care coordination follow-up. Meetings include weekly staffing between DCS CHP and its contracted MCO of members who are inpatient and/or in a behavioral health level of care, monthly Transition Aged Youth Rounds between DCS CHP and its contracted MCO, and monthly Internal DCS CHP Case Review.

Reporting

DCS CHP and its contracted MCO submit a quarterly report to AHCCCS identifying the number of special health care needs members who are in care management.