Solutions for a Healthier Life

MCCW Care Coordination

Medically Driven Care Coordination – For MCCW children who are enrolled in the Waiver and the Medical Homes Network

  • Coordination of chronic and preventive medical management
  • Conduct health related assessments

           o  Health risk assessment with child
           o  Developmental assessment
           o  Disease specific assessment

  • Ensure “best practice” guidelines are followed for acute illness, prevention and chronic care management
  • Coordinate specialty care services with other providers
  • Review and interpret subspecialty recommendations
  • Provide continuity of care for inpatient and outpatient problems 24 hours a day
  • Create and maintain an Emergency Medical Plan to be used by EMS personnel and caregivers at home
  • Coordinate medical services, allied health (OT, PT, Speech Therapy) and other EPSDT services
  • Facilitate participation of health related team members in care planning
  • Provide family training regarding medical care in the home
  • Conduct family training to address disease management and when appropriate the child’s management of their medical condition
  • Monthly physician evaluations to reassess the plan of care and ensure new needs are addressed through the care coordination process

Community Based Care Coordination – For MCCW Children who are enrolled in the Waiver Only

  • Coordinate overall Care Coordination Plan ensuring integration and coordination of waiver services
  • Ensure participant/family-centered care
  • Ensure freedom of choice when educating waiver participants to the choice of providers for services
  • Coordination with other providers (e.g., early intervention, Department of Social Services, etc.)
  • Evaluate and refer to appropriate community/state programs to meet care needs
  • Facilitate transportation to Medicaid services
  • Assure health, safety and welfare as required in the 1915c waiver

           o Ongoing assessment of home environment to address barriers for caring for the in the home
           o Maintain liaison with Department of Social Services – Foster Care.

  • Assess member and provider satisfaction
  • Re-evaluate Care Coordination Plan on an on-going basis, provide recommendations for amendments to the plan
  • Discharge planning for participants with recommendations for termination and transfer out of the MCC waiver as appropriate
  • Discharge planning and transition to another waiver and/or PCP/MH upon aging out of MCC waiver