Exceptional Needs/Special Needs Care Coordination (PT, Days)

The Exceptional Needs or Special Needs Care Coordination nurses (ENCC in OR/SNCC in WA) provide contractually required assistance and support to Kaiser OR and WA Medicaid Members. Kaiser Permanente has expanded the program to include all Charitable Coverage members with special needs; KP Transitions and KP Child Health. The ENCC/SNCC are responsible for: 1) Identification of members who are aged, blind, disabled, or who have other medical and/or cognitive issues that create barriers to care; 2) Coordination of internal and external services to ensure appropriate access and care planning to include other KP staff such as case managers and social work; and 3) Identification and remediation of barriers to care and access that resulting in population disparities.

• Identify appropriate Medicaid and Charitable members for enrollment screening using case finding methods:
  
  
  
  • Likelihood of Hospitalization score, care gap scores, over/under use of ED/UC, appointment cancellations and no-shows, medication non-compliance and the dx codes for children and direct referrals from agency case managers, primary care providers, or other sources.
  
  
  
  


• Independently and proactively complete chart reviews, screening calls and full assessments related to the anticipated level of care and document findings using approved documentation tools.


• Triage findings from member assessments, identifying needs and issues and plan appropriate interventions.


• Determine Level of Care. 


• Communicate findings and actions to involved care providers through succinct summaries that include findings, actions and further recommendations.


• With the member/family and appropriate KP staff and providers, develop a care plan that addresses short term goals that are specific, attainable and measurable and work with PCP to ensure a clear medical treatment plan is documented.


• Provide care coordination and management services for members with identified needs within the scope of the ENCC/SNCC role by:
  
  
  
  • Creatively using available and appropriate resources, including KP staff and providers, to support the unique needs of each member with special needs; Facilitating access to internal and external services; Monitoring the effectiveness of the interventions; and Reinforcing the treatment plan through medication compliance including support for Opiate Therapy Plan compliance; and Advising and coaching patients and families; Identify non-medical issues; environment, abuse and neglect, homelessness and hunger and other safety concerns and work with state agencies and KP providers to support and remedy where possible.
  
  
  • Provide care management and oversight to members participating in the Patient Review and Coordination Program for WA Medicaid. 
  
  
  • Succinctly document interventions in HealthConnect as needed by other providers to ensure coordination of care and services.
  
  
  • Add relevant intervention details to the Special Populations Registry.
  
  
  
  


• Strengthen and update the ENCC/SNCC program through:
  
  
  
  • Education of staff/clinicians about ENCC/SNCC and the special needs of our low income population.
  
  
  • Development and distribution of education, tools and materials for member coordination.
  
  
  • Completion of an annual program review including related policies, desk procedures, and documentation tools.
  
  
  
  


• Act as a liaison between KP, other HMOs, and county and state organizations.


• Actively participates in Kaiser Permanente committees and workgroups and in county/state committee and functions.