Section 1: Overview of Medicaid and Case Management for Children and Pregnant Women

Overview of Case Management Services

Case management is a benefit for individuals from birth through age 20 who are enrolled in Medicaid in Texas. Texas Health Steps provides comprehensive child health services that include regular medical and dental checkups, case management, and medically necessary health-care services. Case management is also provided to pregnant women who are eligible for Medicaid and meet other criteria.

In this section, we'll introduce the key tasks and responsibilities of case managers who provide service to clients enrolled in Medicaid.

Key Tasks

1. Identify the needs of clients and their families.

  • Ask questions.
  • Ensure the needs are current.
  • Ensure the needs are confirmed by the client, parent or guardian.
  • Accurately document the needs.

2. Identify strengths and challenges.

Identify barriers to addressing needs.

3. Research and get to know the resources available in your area.

Link clients and families to local resources and encourage them to take advantage of available services.

4. Empower clients.

Educate clients, so they learn how to access services in the future. Encourage clients and families to become active participants in their health care and seek solutions to their psychosocial, financial or educational concerns.

5. Deliver services in a culturally sensitive manner.

Be aware of:

  • Health-care beliefs
  • Abilities and disabilities
  • Language preferences or barriers

SCENARIO

Suzy, the case manager, researched mental health providers before the first visit with the client’s mother. She called providers to ensure they take the client’s fee-for-service Medicaid and are accepting new patients. Suzy gave mom the names and phone numbers of three mental health providers located close to the family.

Note the work the case manager did prior to the visit: researched, called and gave mother a choice of providers.

Give It Some Thought


The Boundaries Within Case Management

Some people may need only Information and Referral (I & R) and not case management.

Examples of I & R:

  • Providing information on a food bank.
  • Giving the phone number for medical transportation.
  • Referring the client to Texas Health Steps to find a primary care physician (PCP).

scenario

Judy got a call from a mother who wanted help getting school supplies for her child. Judy asked the mother more questions about her child and found out that he does not have a health condition or health risk and does well in school. Judy provided the mom with a list of phone numbers for local resources that can help with school supplies.

This is an example of I & R. You will receive some referrals that are not eligible for case management. Your role is to direct them to resources.

Medical Services

Medical and other clinical services are separate and distinct from case management.

Some parents may ask the case manager questions about their child’s diagnosis. Because each child’s diagnosis may vary, case managers need to refer the parent back to their child’s physician or the diagnostician for more education. For example, a child diagnosed with autism may function very differently than another child with the same diagnosis.

Note

Case Management is not:

  • Providing health care or health education.
  • Providing clinical, medical or therapy services.
  • Diagnosing a client.
  • Determining a need for a specialist.

Quiz

Are the following appropriate case manager (CM) activities?

CM connects pregnant women with a domestic violence shelter.


CM only provides the phone number to Texas Health Steps for dentists.


CM checks the client’s blood pressure during a visit.


CM makes a recommendation that the client should see a health care specialist, such as a cardiologist.


CM refers the client to state programs that may provide assistance, such as Medicaid Waiver Programs, and helps put them on the waitlist.


CM attends a school meeting with a parent at the parent’s request to advocate for services for their child.


CM makes a mental health diagnosis and shares the diagnosis with the parent.


CM educates the parent about their child’s diagnosis.


CM educates the parent about Supplemental Security Income and how to apply.


CM educates the parent about Early Childhood Intervention and makes a referral. CM follows up with the parent to see if their child is receiving services.


CM assists the pregnant woman who’s homeless and has a history of drug use to find shelter and services.