#1 Michelle Tracy:
Michelle was referred a 3 year-old TANF member with a history of microcephaly and autism for case management support due to COVID-19. The member had significant family history and risk factors. The member lives with his grandparents but has parental involvement. When Michelle began working with them, he had aged out of Birth to 3 and was currently not receiving any therapies and was not in school. Michelle worked with the family to prioritize needs and set the first goal of getting member into appropriate therapies to minimize behaviors and ensure developmental progress and safety. Another need related to developmental delay centered around incontinence. Michelle worked with his PCP and DME suppliers to get incontinence supplies set up for him. The family also identified financial hardship needs. Based on the member's diagnosis and delays, Michelle referred the member information to MedData for SSI application support. Michelle also referred the member to CSHCN, via Screener and review. His application remains pending.
Michelle's biggest task and primary goal involved searching for ABA programs in the area because there were none noted in the The Health Plan directory. Michelle knew these services were key in meeting developmental goals, ensuring safety and supporting this family's self-management of his injurious behaviors. Michelle was able to find an ABA provider through an on-line search and phone interactions and justify the need for a contract to support this member's services with the UM department at MHT rates.
The member has a confirmed diagnosis of autism which negatively impacts his ability to communicate his wants and needs. He is non‐verbal, not potty trained, very limited/restricted diet with food aversions, engages in self injurious behavior (biting self and head-banging) and frequently elopes from home.
ABA was able to be approved for 20 hours a week and member is doing great in his ABA program. He has developed appropriate attachment to his teacher. Through education and support, the family has installed safety locks and gate locks and there has been no more elopement. The member now shows the ability to follow simple commands at times and is progressing in behavior management and in social interaction. The family is very thankful for the help Michelle was able to give them in achieving their goals for self-management. His case was closed; all of the goals they developed together were met.
#2 Laura Grubler:
A member who Laura follows for disease management called to say her mail order medications were stolen from her porch and that the insurance wouldn’t authorize any replacement refills. The member is part of the incentive program in which her diabetes and other qualifying meds are at no cost. Working with Walgreens and FedEx, Laura initiated a claim for the meds. Laura contacted client services to see if they would authorize a one-time override so the member wouldn’t have to do without her ninety-day supply of meds and diabetes equipment. She also contacted member PCP to let her know that the member would be without her meds if the override was not approved. Laura spoke with the client services pharmacist who approved the refills but denied paying for them a second time. Because it would be too costly for the member to pay for the meds out of pocket, Laura reached out to her PCP to see what they could do to help. Initially, the doctor prescribed a short acting insulin, but the copay was again too much for the member to afford. Laura suggested to doctor that she consider prescribing Rely On R insulin from Walmart, which is ¼ the cost of Humalog. Although the outcome was not ideal, the member will have something to get her through until March when her regular 90-day supply would be approved. Between speaking with many nurses at the doctor's office and the endless transfers within FedEx, most of 2 days were spent making sure that the member did not go without; but Laura says it was worth every minute.