For people with complex, long-term and chronic health needs, accessing services is a daunting task. They find themselves confronted with a dizzying array of fragmented healthcare, long- term care, and community services programs and providers. They become involved in programs with differing benefits, and eligibility rules, locations, and provider networks. Their care and service needs may be integrated, but the system to serve them is not.

For public and private sector organizations involved in providing care and services to these individuals, the task of providing an integrated plan of care is equally daunting. They are often limited by licensing, funding, and other program requirements that only address a segment of a person's needs.

TMG works with community service, health-care, and long-term care organizations and delivery systems serving people with complex care needs to develop and implement innovative approaches to coordinating and integrating care. TMG works in collaboration with organizations to develop innovations that fit their specific systems and allow them to work across multiple systems.

Two examples of innovative, multiple system delivery services with which TMG has been involved include:

• Integrated Care-The Wisconsin Partnership Program.

  TMG has worked closely with the Wisconsin Partnership Program-a variation on the PACE integrated managed care model in which the consumer, the consumer's community physician, and a nurse practitioner lead a care team. Started in 1997 as an 1115 Demonstration with Robert Wood Johnson Foundation support, the Wisconsin Partnership Program provides a complete range of primary and acute health-care, long-term care, and community services to the elderly and physically disabled. Services are provided by community-based, not-for-profit managed care organizations that receive capitated funding and operate 'at-risk.' TMG has worked with the design and implementation of the program statewide, and with each of the program sites on the development of provider networks and contracts, staff training, marketing, and program expansion.

• Care Coordination and Management-The Milwaukee Single Coordinated Care Plan.

  Single mothers with substance abuse histories are a significant sub-set of the long term AFDC/TANF population. Many of these women are approaching expiration of their five-year lifetime TANF benefit. This fact is causing state and local officials to seek approaches that can facilitate their successful transition to independence. Typically, these women are involved in multiple service systems and, sadly, their successful recoveries are often thwarted by lack of coordination among the various systems that serve them. The conflicting demands of the various social service systems with which they're involved often make success impossible.

  To answer this systemic problem, the innovative, inter-system, Single Coordinated Care Plan (SCCP) was developed to bring multiple delivery systems together in one person-centered, consumer-oriented care plan. TMG has facilitated for Milwaukee County the creation, refinement and implementation of the SCCP care plan among such divergent social service agencies as W2, Child Welfare, Corrections and the AODA treatment providers.

With such a wide variety of experience working with unique long-term care delivery systems, TMG is well positioned to:

• Help provider organizations, private industries, state agencies and local governments design and implement the best delivery system to meet their particular situations.
• Help organizations with strategic planning.
• Partner to replicate or expand existing programs.
• Assist in provider network development and contracting.
• Develop case management and service coordination tools, processes, and training.
• Foster business development and business modeling.