Case Manager Conversations

Jeanne C.

Looking for some advice

I have a meeting this week with the case manager/social worker assigned to my husband by the Medicaid managed care insurance company. It's our quarterly check in. I'm not sure how open to be with her. She's our gateway to services so I'm inclined to share with her, but I also know that she works for the insurance company. I want to make sure that I don't overshare, especially if it's something that could impact his care level.

Does anyone have experience with these meetings and can offer advice on topics to cover in depth or be more cautious about? Thanks!

M1

Jeanne, your level of benefits is generally reviewed once a year, and the hours assigned are generally based on his needs for hands-on care (assistance with bathing, grooming, dressing, toileting, walking, feeding) as well as some allowance for help with meal prep and setup, cleaning, laundry, shopping, and escort. There is some allowance sometimes for extra time if the primary caregiver works outside the home. You might ask if this is your annual review, or find out when your annual review is scheduled. they will be interested in any changes in his condition and yours (improvement could result in a decrease in hours, while worsening could result in an increase in hours).

clever_bear

Hi @m1 and @Jeanne C. 

I believe Jeanne is saying that the social/case worker with whom she is scheduled to meet is actual through her husband's insurance plan. She's not referring to the state grant program providing hours of in-home help. If I'm understanding Jeanne correctly, a good analogy would be medicare or other private health insurance except this is via the medicaid program through the state. In most states, the state has private contracted out medicaid services to private insurance companies to manage them. Thus, the managed care part... very succinctly.

I wish I had some specific advice for you. I have the same basic general suggestions that I'm sure you've already thought of:

-- keep answers to the point

-- someone who is out to help you will ask questions that will benefit you; someone who is out to screw people will find a way to do it if you give too much information with the questions they ask.

-- come with a few questions of your own, though that may be hard if this is routine

-- accept any information they have to provide on any programs or resources even if you think you don't qualify or already have the pamphlet

-- the squeaky wheel thing is often true

I work for managed care insurance. Please don't take the below as defending manage care, because that is far from what I'm trying to do here.

People have this idea that the main goal of managed care is to deny services. While it's true that one way manage care saves both insurance and patients money is to put prior auth requirements in place for expensive, invasive, or possibly frivalous services. Another far more helpful way managed care companies cut costs is to provide some guidance and/or case management to help patients make the best treatment decisions for them. This might mean helping someone research or locate treatment for a specific condition or educate on benefits around a particular thing. The company i work for is small and so does these services well and ultimately to the benefit of patients. Rarely do I see managed care limiting access or harming people's ability to access care. But that's not the companies that contract for medicaid, although the model is similar.

I don't know if anything of this helps. I hope others have other suggestions for you.

Take care of yourself.

Jeanne C.

https://alzconnected.org/discussion/comment/196367#Comment_196367

Thank you. Very helpful. I do have issues to discuss. We've been struggling with the home health agency (lack of coverage for some of the allotted hours, had to remove one aide due to shift abandonment). We're still waiting on some of the promised services. I try to be understanding and polite, but I strongly believe I need to advocate for my husband so he gets what he needs. I'm trying very hard to keep him home. Following your advice, I'll answer questions succinctly and not overshare. I already have my questions written down. I'm not sure why I'm nervous about this.

Jeanne C.

https://alzconnected.org/discussion/comment/196331#Comment_196331

Thanks. We only started services in November, but I'll definitely get info about the annual review.

M1

Lack of staffing remains a huge issue. Even though someone is approved for hours is obviously no guarantee that they'll be staffed. Sounds like this is your first quarterly review, so a change in hours shouldn't occur now unless there were some dramatic change (say, in your own health). I would carefully go over how many shifts have been missed, and you are well within your rights to ask about staffing, about whether alternative agencies should be considered, or even whether you could hire a friend or family member to provide the care ( that is generally called consumer-directed care, as opposed to hiring through an agency). These should be questions they are used to answering and would not jeopardize your benefits to bring them up.

Jeanne C.

@clever_bear @M1 thank you both. Meeting was painless. We are looking at a new agency now so 🤞

M1

Glad it went smoothly, next time you'll know what to expect. Hope the agency change works out too.

clever_bear

https://alzconnected.org/discussion/comment/196367#Comment_196367

I want to validate your anxiety. As anyone who has ever engaged with a large bureaucractic system can attest, there's always the very real fear of being just a number instead of a real person, a family, with real needs and concerns. These systems enact real changes when they work well, and thus can due real harm when they fail as well.

All we can do is our best to understand our rights and responsibilities as recipients/consumers.

I read a little further down and am glad to hear the meeting went relatively well. Hang in there, and hopefully you will be less worried about your next meeting now that you know what to expect.