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Provider and Facility Reference Manual

Section 7 - Case and Disease Management Services

A variety of clinically based programs are in place for addressing the needs of members across the continuum of care, including multiple health management programs to address the needs of members with complex health care needs, those with physical or developmental disabilities, multiple chronic conditions and severe mental illness. These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagement in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals to address health disparities through cost-effective and tailored health solutions.

Case Management Services

The case management program assumes responsibility for the coordination of care for members identified with complex or high-risk conditions. This program is aimed at improving the health of the member population across the continuum of care. The role of the case manager is to promote quality care and meet the member’s/caregiver's needs while maximizing benefits and assuring proper use of services in the most appropriate setting.

Who is eligible and how are members identified for the program?

All members actively enrolled in the plan are eligible for case management services.

Members can be identified for services through:

  • Health Information Line referral
  • Predictive modeling reporting
  • Outpatient medical claims/inpatient hospital claims
  • Pharmacy claims
  • Provider referrals
  • Member or care giver self-referral
  • Staff referrals (including Utilization Management and on-site nurse referrals)

Are there different types of Case Management Services?

Yes, there are several different types of case management. It ranges from general needs of members with multiple comorbidities to highly specialized, disease-specific case management.

The different categories of case management we address are:

  • Behavioral Health/Mental Health and Substance Use Disorder
  • Alzheimer’s/Dementia
  • Chronic Kidney Disease
  • Complex Case Management for high risk members with multiple comorbid conditions
  • Spine     
  • Hip and Knee
  • HIV/AIDS
  • Maternal-Child for high risk pregnancy (Right Start program)
  • Oncology
  • Palliative Care
  • Transplant (transplants such as heart, lung, kidney, pancreas, or bone marrow)

What services are offered to our members who enroll?

  • A member-focused care plan developed using their provider’s direction
  • One-on-one intervention, on the telephone, from a case manager to the member, including education on disease state(s), care plan development, care coordination, and additional resources for information
  • Regularly scheduled telephone communication that allows the member to be monitored at home and assists members with condition self-monitoring
  • An interdisciplinary team approach including  nurses, social workers, dietitians, and pharmacists to interact with members
  • Ongoing assessment to determine level of support available to the member
  • A single, direct contact for member when issues arise
  • Coordination of services with the primary care provider or specialist, as indicated to achieve successful care transitions
  • Referral and linkage with local and community services, when applicable
  • Direction to health education providers to maximize their benefit and support adherence to treatment plan
  • Address any social determinants of health impacting members’ health, functioning and quality of life outcome and risks

Behavioral Health Case Management Program

The fundamental focus of the Behavioral Health Case Management program is to identify members at highest risk of poor health outcomes, including members with mental health and substance use disorders such as first episode psychosis, mood disorders, attention deficit disorders, autism, and opioid dependence. Behavioral Health Case Managers use a person-centered approach, developing personalized plans, and providing appropriate access to covered services.

This integrated care approach focuses on health literacy, utilization of community supports and resources to assist members in navigating the health care system and comprehensive care coordination. This infrastructure will help to provide members access to the care they may need in a timely manner while enabling increased quality and better health outcomes.

A behavioral health case manager will use referrals, risk stratification, hospital discharge notifications, and emergency room visits to identify members eligible for the program.  Collaboration between contracted providers and behavioral health case management staff is necessary and is an expected condition of provider participation.

Additional Resources:
To obtain additional information about our Case Management program, please contact us at 1-877-878-8785, option 2.

Disease Management Services 

Our Disease Management Programs are population-based, risk-stratified, goal and outcome oriented programs that aim to align the member, caregiver, provider delivery system and planned interventions to improve the health of members. Disease Management has established an integrated model with the focus on meeting the needs of members with chronic conditions through care management services, member education, empowerment and support.

Disease Management Program interventions have been implemented to assist members/caregivers in understanding their disease, promotion of self-management skills and development of a collaborative relationship with the providers to help decrease complications while also managing health care costs. The Disease Management team consists of nurses, dietician/certified diabetes educators, social workers, respiratory therapist, and outreach workers to assist members.

Who is eligible and how are members identified for the program? 

  • All members actively enrolled in a plan with a disease management diagnosis are eligible for disease management services. 

Members can be identified for services through: 

  • Health Information Line referrals 
  • Member or care giver self-referral 
  • Predictive modeling reports
  • Outpatient medical claims/inpatient hospital claims 
  • Pharmacy claims
  • Provider referral
  • Staff referrals (including Utilization Management and on-site nurse referrals)

Are there different types of Disease Management Services?

Yes, we offer disease management programs for the following conditions:

  • Asthma
  • Attention-deficit hyperactivity disorder (ADHD)
  • Cardiovascular Health 
  • Chronic Obstructive Pulmonary Disease (COPD) 
  • Depression 
  • Diabetes 
  • Hip and Knee 
  • Obstructive Sleep Apnea 
  • Spine Health Management
  • Substance Use Disorder 

What services are offered to our members who enroll?

  • Support and health care guidance for members with chronic illnesses 
  • A member-focused educational plan is developed using evidence based guidelines
  • One-on-one intervention, via telephone and/or mobile app communication, from disease care manager to the member, including education on disease state(s), care plan, and resources for information 
  • If needed, follow-up scheduled telephone communication that allows the member to be monitored in his/her home 
  • A single, direct contact for the member when issues arise, a registered nurse is assigned to the member for the duration of his/her health care needs 
  • Direction to local and community services, when applicable 
  • Direction to health education providers to maximize their benefit and support adherence to treatment plan

Additional Resources:
To obtain additional information about our Case Management program, please contact us at 1-877-878-8785, option 2.

Our Commitment to Practitioner Rights

 

  1. You have the right to request information about our services, staff qualifications, and any contractual relationships.
  2. You have the right to work with or decline to participate in our patient programs and services.
  3. You have the right to be informed how we coordinate interventions with treatment plans for individual patients.
  4. You have the right to know how to contact the person responsible for managing and communicating with your patients.
  5. You have the right to be supported by us when interacting with patients to make decisions about their health care.
  6. You have the right to receive courteous and respectful treatment from our staff.
  7. You have the right to communicate complaints, or other feedback to us by calling Provider Service at 1-800-471-4685.