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Service Coordination

Key Considerations

Service coordination, the planning and management of multiple services and supports, is a critical feature of any LTSS program.  This resource uses the term service coordination generically, though your state may call it care management, support coordination, or case management.  The scope of the service coordination will depend on your state’s program goals and model. 

If your MLTSS program is limited to long-term services and supports, service coordination will focus on LTSS. However, to ensure a whole-person approach, the service coordination specifications should also be explicit regarding how service coordinators interface with primary and acute care providers and how informal and community supports beyond those that Medicaid reimburses will be included.  The Wisconsin Family Care program offers a good example of this approach.  The program provides primarily LTSS and therapies but requires coordination with formal and informal caregivers, as well as formal and informal out-of-program services and supports. picture of beneficiary meeting with providers

If your state’s program includes full integration of LTSS with primary, acute, and mental health services, including those funded by Medicare, service coordination will be a key integrating mechanismMinnesota Senior Health Options program is an example of a fully integrated Medicare-Medicaid program.



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