If you live in Minnesota and are dual eligible for Medicare and Medicaid, there’s help available to navigate your health care decisions so you don’t have to do it alone. A Minnesota Senior Health Options (MSHO) or Minnesota Senior Care Plus (MSC+) plan includes the help of a Care Coordinator who works with you to be well and healthy. This service is at no cost.

What is a Care Coordinator?

Care Coordinators are registered nurses or licensed social workers. They work with you to review your health, set goals and a plan, and make it happen with your health care team, county workers and insurance plan.

They will:

• Meet with you (options available)
• Explain how your plan works
• Navigate how your Medicaid and Medicare coverage work together so you don’t have to
• Partner with you to understand your key health goals and collaborate with you to create a person-centered care plan
• Complete assessments with you and help you get services within Medicare and Medicaid, if you’re eligible. This includes services like Elderly Waiver, personal care assistance, chore and companion services, home health care, assisted living, transitional care, nursing home care, and end-of-life care

What to expect with your Care Coordinator

You and your Care Coordinator will complete a health risk assessment, make a person-centered care plan and follow up at least once a year. Here’s how each step works:

Health risk assessment

You and your Care Coordinator will talk about what is most important to you and what you need to be healthy and safe. This is a time to ask and answer questions. Together, you’ll look at what you have and what you need to maintain your health or achieve your health goals.

The goal of the assessment is to identify your needs and goals and create a person- centered care plan around you. If you feel you are managing your health and don’t need any services at this time, your Care Coordinator will check back in with you the following year.

Person-centered care plan

When you’ve identified your health needs, your Care Coordinator will create a care plan that identifies the support, equipment and services that could help you.

Here are some examples of what a care plan could include:

• Help with chores in your home or yard
• Safety equipment in your bathroom
• Help with personal care
• Help with prescription refills
• Home-delivered meals
• Physical therapy or speech therapy
• Adult day care services

Your Care Coordinator shares your care plan with your doctors, gets physician orders or approvals if needed, and connects you to community resources like food shelves, transportation, energy assistance or housing help. You can choose which providers you want or the Care Coordinator can help find providers for you.

Follow-ups

Expect your Care Coordinator to follow up with you to make sure everything is in place and your care plan is successful.

You’ll then talk every year to review the plan and make updates as needed.