In what made for an informative and insightful event, Independence Care System’s (ICS) Senior Vice President of Clinical Programs and Population Health Rachael Stacom and Disability Program Director Elaine Castelluccio offered a live webinar on the significance of disability-competent care and care coordination.
The session was hosted by Resources for Integrated Care (RIC)—which partners with advocates, health plans and providers—to disseminate promising practices and tools for the care of people covered by both Medicare and Medicaid. The webinar was supported by the Medicare-Medicaid Coordination Office (MMCO) of the Centers for Medicare and Medicaid Services (CMS). MMCO’s goal is to assist individuals in getting accessible, high-quality health care with covered services in both programs.
Stacom is a multiple sclerosis-certified nurse practitioner who created ICS’ MS program, which has been designated an MS Society Partner in Care. Castelluccio, a physical therapist, spearheaded ICS’ Peer Mentoring/Independent Living Program, which addresses the needs of ICS members with spinal cord injuries (SCI) and MS by pairing them with mentors who have adjusted to living with similar conditions.
ICS’ mission and care management
Stacom and Castelluccio discussed the ICS Health Home program and its mission of ensuring that people with disabilities are able to live healthy lives independently, in their homes.
They highlighted ICS’ ability to deliver quality care management, with an approach that emphasizes partnership, respect and expertise to empower members and caregivers, and collaboration with service providers and advocates who work on members’ behalf.
Discussing disability-competent care
Stacom and Castelluccio answered a variety of questions about disability-competent care.
“How can care coordinators best work with providers and community based organizations to make health-related programs accessible to people with disabilities?” one participant asked.
Stacom emphasized the importance of maintaining a culture of listening.
“At ICS, half of our population are wheelchair users,” Stacom said. “What we heard was, they didn’t have access to wheelchairs repairs. So we started a wheelchair repair clinic.”
Stacom also stressed the importance of community partnerships.
“Develop a network of providers who understand this population,” Stacom said. “We work with many resources in the community—the National Multiple Sclerosis Society, Mount Sinai Hospital—to make health programs accessible. Work with independent living centers and organizations.”
Castelluccio added: “We want to try to help and support members themselves to be their own liaisons and to empower them. ICS offers many resources to help members be healthier and to allow them to be their own point person.”
Addressing gaps in care coordination
“Could you describe best practices for coordinating between multiple agencies and stakeholders involved in care?” another person asked.
Stacom noted that with organizations trying to provide care management, everyone wants to assist, but members often feel overwhelmed.
“We create a new plan of care every six months at ICS. You want to do that with the member and provider engaged,” Stacom said. “If you can’t have someone there, you want to coach them beforehand. You want to review goals and how you think you’re going to meet them. You want to create that plan of care and update it regularly. It should always be member focused.”
The final question was, “As a substance use disorder counselor, we are tasked with addressing sleep, diet, exercise, and medication management, including pain medication. What are potential gaps in care coordination to look for when counseling a person who is living with a disability?”
“You need to be aware of barriers and risk factors and how to address them, and develop and maintain a network that can meet those health needs,” Stacom said. “For people to exercise, they need an adaptable gym. For a GYN exam, they need a height-adjustable table to transfer onto. You need to keep the person’s level of functioning at the forefront of your mind.”
For a list of care coordination resources and to listen to the webinar in its entirety when available, click here.