Health Care Guidance Program and 1115 Waiver


 The DHCFP has identified the most pervasive high cost and chronic conditions for persons served through the fee-for-service (FFS) system. Because the care enrollees received in Nevada’s FFS program has historically been unmanaged, the DHCFP estimates that costs for providing care to persons with chronic illness will only escalate. To curtail the costs and provide appropriate care navigation assistance to persons with chronic illness, the State has implemented a comprehensive care management program, namely, the Nevada Comprehensive Care Waiver (NCCW) program. 

To aid in the evaluation of the program, the DHCFP identified the following quality goals to improve the health and wellness of NCCW enrollees and ensure they have access to high quality and culturally appropriate care.  If you have any additional input, questions, or suggestions please feel free to contact us. 

 

Background

The Nevada Division of Health Care Financing and Policy (DHCFP) as well as its sister agencies and counties is partnering with the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Administration (SAMHSA) to develop a model for Health Homes and Care Management and Coordination, both care management systems.

 

Health Homes

A medical home, also known as a patient centered medical home (PCMH), is an approach to a patient’s care and how that care is provided: it is not a home or facility. It is an approach to providing comprehensive care to patients in partnership with their physicians, and when appropriate incorporating their family and other community resources.

A health home is an extension of the medical home concept. Health homes have been defined in the Patient Protection and Affordable Care Act, section 2703 as ‘…a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services.’ The services are the same core concepts as the medical home approach, but it incorporates the entire scope of the recipient’s care including, but not limited to; behavioral health, long term care, transitional care, care coordination, referral to community and social support services, as well as use of health information technology to link services where feasible.

Nevada is looking at new and innovative ways to incorporate these concepts in to the health care provided to Medicaid recipients. Nevada is working towards developing health homes and care management programs with providers as well as focusing more on care management with recipients and utilizing care coordinators. This is a very holistic form of care ensuring a higher level of health care for Medicaid recipients and accountability and whole person care from providers.

 

Care Management Organization (CMO)

Nevada is also working to contract with a Care Management Organization (CMO) to assist in coordinating and managing the care of recipients with chronic conditions and frequent emergency room visits, or high utilization. A CMO functions similarly as a health home in that its function is providing comprehensive care to patients. This is similar to health homes in that a CMO oversees the entire scope of the recipients’ care including, but not limited to: behavioral health, long term care, transitional care, care coordination, referral to community and social support services, as well as use of health information technology to link services where feasible.

The difference between a health home and a CMO, is that a health home is maintained at the physician level. It is physicians networking with other physicians for a patient’s care. A CMO is a vendor that only oversees care managers that work as advocates and guides for patients through the health care system. Care managers are there to assist patients in understanding what the next step is in managing their health care needs as well as linking them to additional resources as needed.

These programs are not creating new eligibility categories for recipients, but restructuring what is already in place.

These programs are still under development and more information will be posted as available. Public workshops will be held periodically to update stakeholders, advocates and recipients.

Last Edited: 7/13/2017