Care Management Programs
We provide programs for members with chronic and complex medical and behavioral health conditions, as well as identified socioeconomic barriers. The goal is to help members and their providers to better deal with these conditions, follow the prescribed treatment plan, and prevent additional complications. These care management programs may include care coordination; support of patient-centered medical homes and health homes; non-emergency medical transportation; wellness and prevention programs; chronic care management (disease management) programs; high cost/high risk member management programs, pregnancy programs and a special needs program. In addition, these programs may include a personal care manager, a personal care management plan, educational materials, and collaboration with the members’ clinical team. Population based (disease management) programs include interventions targeted to the condition being managed. For example, the diabetes disease management program includes provider reports that include members’ HbA1c levels and missing diabetes testing such as eye exams. The asthma program includes provider reports with members’ medication histories for controller and rescue medications.
If a member is identified for any of the programs listed below and agrees to participate, a care manager will notify you, the provider, by letter or telephone and work to coordinate your patient’s care. Contact your Provider Relations Consultant to find out what reports are available about your patients. If you would like to refer a member to our complex care management or any condition-specific program such as diabetes or asthma, please contact our care management department at 866-853-5241 or complete and submit the referral form. Our care management staff will evaluate the member and enroll him/her in the most appropriate program(s) based on condition, severity of illness and individual needs.
Care Management Services Offered
Population Management (disease management) is an intermediate-level care management program with a focus on helping members develop self-management skills, arranging services, and providing health education for members with specific medical, behavioral, and social needs. In addition, Population Management interventions may include smoking cessation, diet and nutritional counseling, wellness and prevention, and others for the following targeted medical populations:
- Heart failure
- Pregnancy and high risk pregnancy
- Coronary heart disease
Complex Care Management targets the most complex, highest risk members, including those with special health care needs for which a multidisciplinary approach is utilized, focusing on helping members develop self-management skills, arranging needed services, and providing education to meet the varied health needs of this population.
Medical conditions that may be appropriate for a care management referral include, but are not limited to:
- Bariatric Surgery
- CVA or other degenerative neurological or neuromuscular disorders
- Spinal cord injury/traumatic brain injury/anoxic brain injury
- Complex newborn/NICU stay
- Neonatal abstinence syndrome/shaken baby syndrome
Indications that a patient may benefit from a referral to Complex Care Management for any medical condition (including one managed through a population based program) include, but are not limited to:
- An illness or event that has caused a change or decline in ability to self-manage
- 5 or more chronic condition medications
- 5 or more different specialists
- An acute inpatient stay with LOS>7 days
- Multiple admissions/readmissions
- Multiple or repeated emergency department use
- Homelessness, poor or inadequate living environment