Service Coordination (Case Management) 

Our Service Coordination department uses a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet our members' healthcare needs through communication and available resources to promote quality, cost-effective outcomes (Source: Care Management Society of America). At Parkland Community Health Plan, we attempt to assist in the efficient utilization of medical resources for our members with special healthcare needs, including highly complex chronic and catastrophic cases, to improve access to quality care and avoid unnecessary medical costs. Members who might benefit from education, care, service, assistance with non-medical drivers of health (social determinants of health), and/or resource coordination services are identified for service coordination through utilization management activities, health risk assessments, and screening of administrative data. 

Through outreach calls, we establish a connection with members to talk about their participation in our service coordination program. When a member agrees to participate, we complete an initial health needs screening and work with them to create a service plan (care plan). That plan is mailed to the member and their provider. A PCHP service coordinator follows up with the member to check their progress on meeting their service plan goals and updates the member’s goals based on their needs. Members and providers can also contact the service coordination department directly for assistance and referrals. 

Clinical Practice Guidelines 

Clinical practice guidelines summarize evidence-based management and treatment options for specific diseases or conditions. 

Practice guidelines are developed nationally and adopted locally through the Provider Advisory Committee that includes practicing physicians who participate in the plan. This group also suggests topics for guideline development, based on relevance to enrolled membership, with high-volume, high-risk, problem-prone conditions as the first priority. 

The Parkland Community Health Medicaid and CHIP programs have adopted the following guidelines: 

Cultural Competency 

Good communication between members and providers contributes directly to patient satisfaction and positive outcomes 

A culturally competent provider effectively communicates with patients and understands their individual concerns. It’s incumbent on providers to make sure patients understand their care regimen. 

To improve individual health and build healthy communities, providers need to recognize and address the unique culture, language, and health literacy of diverse consumers and communities. The Cultural Competency program is geared toward the following: 

  • Improving healthcare access and utilization 
  • Enhancing the quality of services within culturally diverse and underserved communities 
  • Promoting cultural and linguistic competence as essential approaches in the elimination of health disparities. 

Additional provider-focused cultural competency resources can be found through the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA). 

Culture is a major factor in how people respond to health services. If affects their approach to: 

  • Coping with illness 
  • Accessing care 
  • Working toward recovery 

Providers receive education about such important topics as: 

  • The reluctance of certain cultures to discuss mental health issues and of the need to proactively encourage members from such backgrounds to seek needed treatment 
  • The impact that a member’s religious and/or cultural beliefs can have on health outcomes (e.g., belief in non-traditional healing practices) 
  • The problem of health illiteracy and the need to provide patients with understandable health information (e.g., simple diagrams, communicating in the vernacular, etc.) 
  • The history of the disability rights movement and the progression of civil rights for people with disabilities 
  • The physical and programmatic barriers that impact people with disabilities accessing meaningful care 

As part of our cultural competency program, we encourage our providers to access information on the Office of Minority Health's web-based A Physician's Guide to Culturally Competent Care. The American Medical Association, American Academy of Family Physicians, and the American College of Physicians endorse this program, which provides up to 9.0 hours of category 1 AMA credits at no cost. 

Condition Management Guidance 

Parkland Community Health Plan offers condition management programs for asthma and diabetes. Members receive education, coaching, and other services to help them better manage their health. Service coordinators connect one on one with members to perform or facilitate health risk assessments and develop an action plan based on the member’s understanding of their condition, need for equipment and supplies, referral for specialty care, or other special considerations due to co-morbidities, including behavioral health and substance abuse. The programs include interventions focusing on removal of barriers to care, promotion of members’ adherence to their healthcare treatment plans, lifestyle risk factors, and common self-management skills. All these condition management services are managed through the delivery platform to effectively coordinate the care for members with these chronic conditions and risk factors.  

Referrals 

In-Network Referrals 

PCPs can refer a Member to an in-network specialist for consultation and treatment without a prior authorization request to PCHP. 

Out-of-Network Referrals  

If the PCP believes that a Member needs to be referred to an out-of-network provider, including medical partners not contracted with PCHP, documentation demonstrating the need must be submitted to PCHP for review and prior authorization before the referral can occur. 

There must be documentation of coordination of referrals and services provided between the PCP and Specialist. 

Routine Specialist care referrals must be provided within 30 calendar days of the referral. 

Members may access behavioral health benefits by contacting providers directly. No primary care referrals are needed. 

Members may access routine vision services, without a referral from their PCP, provided they are coordinated through Superior Vision. 

Requesting a Referral can be done on the PCHP Provider Portal. 

Quality Improvement 

Parkland Community Health Plan has an ongoing Quality Assessment and Performance Improvement (QAPI) program that is comprehensive in scope and focuses its attention on the quality of clinical care and services to our members. The program is tailored toward ensuring that members receive preventive healthcare in a timely manner and providing care management to individuals with special healthcare needs. The QAPI program adheres to state and federal requirements and is overseen by the Governing Board of Directors and Quality Oversight Committees. 

Performance improvement and measurement is fundamental to the QAPI program. What cannot be measured cannot be improved. Therefore, it is through analysis of encounter data that Parkland Community Health Plan is able to identify gaps in care and recommend opportunities for improvement. The QAPI program is always seeking provider involvement, feedback, and recommendations for improving the delivery of care and services. 

Information on Quality Improvement Projects is available upon request.