As an entity contracted to administer health insurance benefits on behalf of CMS Plan, Ped-I-Care is unique in that its eligible population is the most challenging to insure, yet the program itself is continuing to thrive and improve along all areas for which it is responsible. The program has shown itself to be a well-balanced and carefully-thought-out bridge between academic and community medicine, in which children with special health care needs (CSHCN) are able to access world-class health care at affordable rates. Children’s Medical Services (CMS) Nurse Care Coordinators (NCCs) play a central role in serving our members, as described in state and national research publications.
- Ped-I-Care offers high-level managed care, with coverage decisions reviewed primarily by physicians (medical reviews). Only a physician may reduce or deny a service. The plan conducts thousands of medical reviews per year. The advantage of this approach is that it allows Ped-I-Care to provide additional, or more appropriate, services if deemed necessary and appropriate by the Medical Director.
- Members may choose which network physicians they would like to see for services. The program has received national attention for its parental satisfaction scores.
- Ped-I-Care works with primary care physicians and CMS Nurse Care Coordinators to ensure members are current with child health check-ups and immunizations.
- Ped-I-Care has established a network of more than 10,000 contracted providers. All network physicians voluntarily participate in the system.
- Ped-I-Care has a multidisciplinary team led by a child psychiatrist that holds bi-monthly behavioral health case conference calls to discuss and manage the most at-risk and vulnerable members of the population.
- In addition to successful implementation of Performance Improvement Projects, Ped-I-Care is engaged in multiple activities, the aim of which is to increase care, compliance, and quality. Special research projects focus solely on behavioral health care management, efficacy, and efficiency of treatments and interventions. As such, Ped-I-Care is involved in a continual process of self-reflection, self-assessment, internal improvement, and both internal and external monitoring.
With the help of the Provider Relations Liaisons, Ped-I-Care continues to expand its provider network. Since December 2009, there has been a continual increase of providers to the network of primary care providers, dental providers, and hospitals along with specialists, mental health providers, and ancillary providers.
It has been noted that once a provider is recruited into the Ped-I-Care network, the retention record is excellent. This is believed to be a reflection of the quality of support being offered to the providers by Ped-I-Care leadership and staff.
The Role of Nurse Care Coordinators
Central to the service of members is the role of CMS Nurse Care Coordinators in the continuum of care. As described in the September 2009 issue of ON PAR Magazine, NCCs:
“…are responsible for getting to know the needs of each child and then interacting with parents, physicians, and others involved in the health care process so that needs are met in the most appropriate and efficient manner. Based on parents’ feedback, the system is working: In 2006 more than 90% of surveyed families reported they were satisfied with their Ped-I-Care health plan. Compared with an average of 55-60% nationwide, it would seem that the role of the NCCs in facilitating care is pivotal in paving the way for positive health outcomes that lead to happier families.”
In addition to managing the medical needs of each child, NCCs also act in ways which are designed to educate and empower the families of each member, so that dependence is reduced and outcomes are improved. As described in the care coordination guidelines booklet,
“Coordinators know when to push, when to hold back, and when to adjust the speed of interventions. Assessing the developmental readiness is part of timing and detecting. Families are frequently faced with problems and crises. Coordinators work collaboratively to help families work though these crises. At some times families may require intensive support and assistance. As the family gains in strength, competence and self-help abilities, the coordinator’s role may become more consultative rather than prescriptive.”
In essence, coordinators are charged with overseeing and organizing the myriad details of a child’s medical needs and matching appropriate services to meet those needs. Simultaneous to this task and central to its completion are points of focus geared towards independence.
Quality and Utilization Management Committee
The Ped-I-Care program benefits from involvement of its Quality and Utilization Management Committee (QUMC), which meets quarterly to discuss both broad-based and specific issues central to the functioning of the organization. The group is comprised of professionals within and ancillary to the field of pediatrics, as well as inside and outside the organization itself. Physicians, nurses, health care administrators, professional coders, doctors of education, a social worker, and an in-house media and research professional are among the members who participate at each meeting.
Discussions involve such topics as clinical guidelines, medical reviews, behavioral health, therapy reviews, contract reviews, and cultural competency as appropriate. The committee also oversees the Quality Improvement (QI) program through which providers and facilities are reviewed on a regular basis. Results of QI activities are reviewed by the QUMC, which provides guidance and recommendations that improve future quality outcomes and influence policy creation for the program.
Financial Decision Making
The structure of Ped-I-Care is such that only physicians make decisions on the appropriateness and necessity of care. It is believed, empirically, that medical care costs are going down; the program is beginning to research whether this is true, the reasons for this and to what extent. The theory is that because most service requests are approved, children are taken care of, as fully as possible, and in a timely fashion. Costs are therefore decreasing over time because problems are proactively addressed and patients move into the far less expensive maintenance phase of managing their health care condition(s).
Medical and Therapy Reviews
Physicians knowledgeable about children with special health care needs are responsible for medical reviews. For therapy reviews, Ped-I-Care has consultants to review complicated requests for therapy services and to provide recommendations to the medical directors. The Children’s Multidisciplinary Assessment Team (CMAT) reviews requests for private-duty nursing, home health aides, and Prescribed Pediatric Extended Care (PPEC) that combine to total more than 15 hours a day in care. These approaches are unique to Ped-I-Care.
Collaboration with Other Organizations
Ped-I-Care works in conjunction with state experts and the Institute for Child Health Policy (ICHP) at the University of Florida to evaluate performance and satisfaction levels, with the goal of consistently improving access to care and care provision.