NextStep Care (NSC) is a Georgia-based case management organization serving highneed, low-income individuals, based in local Georgia communities in rural, urban and suburban counties. The company provides collaborative case management and advocacy for beneficiaries with high medical, functional and social complexity. NSC was founded in 2001 and serves all 159 counties of the state through14 regional case management offices.
NSC enrolls members for care coordination primarily in enhanced case management through Medicaid’s 1915(c) Elderly and Disabled Waiver Program (EDWP) for home and community-based services (HCBS). More than 5,600 NSC waiver members statewide are currently served through the EDWP’s two programs—Service Options Using Resources in Community Environments (SOURCE) and Community Care Services Program (CCSP). NSC’s July 2023 census for the waiver was over 5,600, with SOURCE enrollment accounting for 97% of NSC members.
Eligibility requirements for the EDWP, both SOURCE and CCSP are:
- Medicaid eligible or potentially Medicaid eligible (SOURCE serves only Supplemental Security Income (SSI) Medicaid
beneficiaries; CCSP eligibility extends to 300% of SSI)
- Assessed as appropriate for the EDWP by a program care coordinator
- Certified as nursing facility level of care at an intermediate nursing home through the same Medicaid third-party contractor
as nursing facilities, Alliant Health Solutions
- Need for services offered by the EDWP at less cost than Medicaid SNF cost of care
The waiver serves members with multiple needs, functional and/or cognitive impairments and significant risk of high utilization of emergency, acute, post-acute and long-term nursing facility placement. Depending on member needs and resources, community services arranged and monitored by NSC through the EDWP provide direct assistance with ADLs:
- Adult Day Health—daytime care and supervision in an adult day center
- Alternative Living Services—personal care home residence for persons unable to remain independent in their own
homes
- Emergency Response Services—in-home electronic support system providing two-way communication between
isolated persons and a medical control center
- Home-Delivered Services—skilled nursing services, physical/occupation/speech therapy
- Personal Support Services/Extended Personal Support Services—assistance with meal prep, bathing/dressing and
light housekeeping (most highly accessed waiver service)
- Consumer-Directed Personal Support Services—consumer hires and supervises worker(s) of choice after 6 months of
traditional personal support services
- Out-of-Home Respite Care—out-of-home overnight respite care in an approved facility with 24-hour supervision
- Home Delivered Meals—prepared outside the home and delivered to the client
Structured Family Support—care provided by a family member who is trained, coached and supervised by a personal
support agency, with additional monitoring by Case Management (CM) agencies
The organization’s 14 offices are located across the state:
- Albany
- Eatonton
- Athens
- Macon
- Augusta
- Metter
- Butler
- Rome
- Columbus
- Thomasville
- Conyers
- Tyrone
- Duluth
- Wrightsville
NSC member characteristics, July 2023:
- Very low income, majority SSI eligible
- Majority residing in Georgia counties designated as rural
- High rates of:
- Diabetes
- Stroke
- Heart Disease
- Hypertension
- Chronic Obstructive Pulmonary Disease
- Dementia
- Age
- Under 65 and disabled: 2,385
- 65 to 84: 2,575
- Gender
- Female: 3,865
- Male: 1,812
- Dually Eligibility, Medicare-Medicaid
- Dually eligible: 3,638
- Medicaid-only: 2,035
- Race
- Black: 3,472
- White: 1,256
- Asian: 747
- Hispanic: 135
- Other: 52
- Indian American: 6
- Pacific Islander: 1
- Limited English Proficiency: 995
- Members dually enrolled in hospice: 56
A majority of referrals for NSC offices come from waiver providers of personal support services in the different regions. The organization works closely in case management activity with personal support agencies and providers of Alternative Living Services personal care homes.
Case managers also coordinate closely with providers of primary and specialist physician care, arranging transportation, scheduling appointments, making reminder calls, etc. NSC offices partner with Georgia Health Advantage to integrate HCBS with clinical care through the Institutional Equivalent Special Needs Plan (IESNP), including weekly joint interdisciplinary care meetings.
Risks related to social drivers of health for NSC members are many,
and include:
- Poverty
- Disability
- Racial disparities
- Physical environment (accessibility, substandard housing, utilities, neighborhood safety)
- Food insecurity (hunger and nutritional requirements for chronic conditions)
- Transportation to medical and non-medical appointments
- Education/low levels of literacy (difficulty managing chronic conditions)
- Community and social context (support systems, community engagement
Case management emphasis in NSC focuses on supporting community residence by members, avoiding preventable
emergency, acute and institutional care, primarily by:
- Ensuring effective and reliable HCBS
- Supporting caregivers in their essential role
- Facilitating care by primary care physicians and other medical providers
- Addressing risks related to social drivers of care by referrals to community-based organizations or referring members for assistance through NSC’s Community Benefits program which provides financial assistance for critical items and services with no third party funding or local resources (incontinence supplies, bed bug treatments, etc.).
Key case management functions:
- In-home health risk and needs assessment completed by LPN with RN oversight, upon member admission, annually and as needed for changes in condition.
- Individualized Care Plans (ICPs) developed for NSC members by case managers with LPN participation, with weekly face-to-face meetings with the NSC Medical Director for complex care planning
- Maintaining regular communication with members and caregivers through a blend of home visits and telephonic contact by case managers and nurses:
- Minimum of monthly telephonic contact with members
- Quarterly face-to-face visits with members
- Communication and contacts with members/caregivers, HCBS providers, PCPs and other clinical and community providers, as needed to maintain optimal member health and functional status
Organization of the company:
- Medical Director for each local office (advises on complex referrals; review, discuss and sign care plans; reviews issues related to chronic non-compliance, potential discharge to SNFs, utilization data as available, etc.)
- Centralized Referral/Intake office
- Centralized Quality and Compliance Department (Registered Nurses)
- Regulatory and Compliance Specialist
- Assessment Coordinators
- Quality and Education Coordinators
- Local Case Management office
- Local office Administrator
- Licensed Practical Nurses (performs in-home MDS assessments)
- Case Management Team Leader
- Case Managers
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