1. Texas Department of Aging and Disability Services
Care Management Program
Community Outreach team
September 15, 2016

2. DADS Program Overview
DADS contracted with AxisPoint Health (APH) to develop and implement a Care Management Program for the state supported living centers (SSLCs) statewide to serve as an extension of the current care teams:
APH has nurses in the 12 SSLCS and the Rio Grande State Center.
Nurses provide evidence-based assessments with a care plan and proactive identification and coordination of physical and behavioral health issues.
APH provides a 24/7 nurse and behavioral health call line for the first 12 months following an SSLC resident’s transition to the community.
APH is developing a community outreach program to help fill gaps in Medicaid provider availability for SSLC residents who transition to the community.
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3. Goals of the Program Independently assess 100% of SSLC residents
Work with STAR+PLUS managed care organizations (MCOs) to increase Medicaid provider willingness to serve individuals with intellectual and developmental disabilities (IDD)
Establish a Program Advisory Board (PAB) to collaborate and strategize on ways to increase MCO and Medicaid provider engagement
Identify and communicate gaps in care to SSLC leadership and clinicians within each facility
Provide Board Certified Behavior Analysts (BCBAs) to complete independent behavioral assessments and make recommendations for selected SSLC residents (to launch fall 2016)
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4. A Team Approach: Integration into Established Workflows
SSLC Team
Develops individual support plans
Delivers direct resident care
Provides detailed documentation and reporting
Collaborates as a team
AxisPoint Health
Supplement care plan tool (VITAL platform)
Integrates care plan into integrated risk rating process
Care Manager complements current care team with information from independent assessment
Coordinates with APH behavioral health analysts
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5. Time Line of APH Activities
October The care management program launched at SSLCs (Now operating at all 12 facilities and the Rio Grande State Center).
April Community outreach work initiated with hiring of two Community Outreach Coordinators (COCs). The COCs met with SSLC transition staff, Local Intellectual and Developmental Disability Authorities (LIDDAs), Hub Learning Communities, and the Texas Council of Community Centers.
July Through discussion with DADS, the focus of the community outreach program narrowed to focus on addressing Medicaid provider gaps for transitioning SSLC residents. Held initial meeting with Texas Association of Health Plans.
August APH community outreach team met the Texas Medical Association; began to recruit PAB members.
Fall BCBA program to start in the SSLCs. Meeting planned with the five STAR+PLUS MCOs. First PAB meeting to be held.
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8. Health Care Provider Gaps
When a Medicaid provider gap is identified for an individual who is transitioning, the following will occur:
The SSLC Admission/Placement Coordinator will notify the state office Continuity of Services Specialist assigned to their facility, who will then notify an APH COC.
The APH COC will reach out to the individual’s proposed MCO to try to locate an appropriate health care provider.
The APH COC will mobilize other resources (through LIDDA contacts, the PAB, APH connections) as needed to try to fill any other gaps identified by the SSLC and communicated to state office.
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9. Program Advisory Board
To further increase its breadth of resources and increase visibility in communities across Texas, APH has created a PAB, to consist of 6-10 health care providers and representatives of stakeholder groups from across the state.
The PAB members will be charged with the following tasks:
Serve as a panel of experts to discuss and vet program ideas and concerns.
Help develop a broader base of Medicaid providers to serve individuals with IDD
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10. Community Outreach Coordinators
Gretchen Golladay, LMSW
Based in Austin
SSLCs: Austin, Abilene, Denton, Mexia, San Angelo, San Antonio
Tracy Edwards, MBA
Based in Houston
SSLCs: Brenham, Corpus Christi, El Paso, Lubbock, Lufkin, Richmond, Rio Grande
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11. Medical Director Lisa Doggett, MD, MPH Based in Austin
Provides clinical oversight to program operations
Supports AxisPoint Health nurse case managers in SSLCs
Serves as contact for SSLC medical directors
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12. Additional APH DADS team members:
Ros Bader, MSW
DADS Program Manager
Oversees all facets of the DADS program
Jacque Waller, RN
Operations/Nurse Manager
Manages the nurses in all 12 SSLCS and the Rio Grande State Center
Jillian Abramson, MBA
Program Administrator
Provides management of Community Outreach Coordinators and program outcome measures
Supports AxisPoint Health DADS team
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13. Thank you for your time Questions?
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