Painted Hills 3

 

Care Management

To refer a member for care management, call 1-800-493-0040.

Download Care Management Article

Goals and Objectives:

The goal of the program is to help members regain optimum health or improved functional capacity in the right setting, utilizing the right providers, in the right time frame and in a cost-effective manner. It involves comprehensive assessment of a Member’s condition, to include but not limited to, determination of the available benefits and resources, and development and implementation of a Care Management Plan with performance goals, monitoring and follow-up. More specifically, the goals established for the Complex Care Management (CCM) Program include:
 The goals of the Complex Care Management Program are to:

  • Improve the quality of life for Members.
  • Improve functional capacity of Members.
  • Increase Member self-care.
  • Improve efficiency by reducing unnecessary emergency department visits and hospital utilization.
  • Enhance access to appropriate health care resources

Criteria for Inclusion in Complex Care Management

The following criteria are used to determine which Members will benefit from the CCM Program. Program criteria were established to provide the opportunity to participate in Complex Care Management for Members with a variety of complex conditions.

Factors distinguishing Complex Care Management typically include a degree of complexity of illness or condition that are severe, requiring a level of management that is intensive and requiring an extensive amount of resources to obtain optimal health or improved functioning. Eligibility will start the date the Member is identified as being eligible for CCM services. Enrollment occurs when the Member has provided consent to receive services.

CCM is a voluntary program, so only Members who agree and consent to the program are enrolled.

CCM Program eligibility criteria are two pronged – Risk factor/s and Complex social needs. 

  • Members may have medical complexity that is compounded by related psychosocial, and/or behavioral health needs.
  • Members with one or more of the following risks:
  • Acute health care needs, diagnoses, or hospitalizations
  • Complex medical issues and/or comorbidities 
  • Poorly controlled disease states 
  • Frequent inpatient admissions 
  • Multiple Emergency Department (ED) visits 
  • Predictive modeling identified risk level (Altruista)


AND one or more of the following needs: 

  • Adherence to treatment (medications, visits, behavior change, diet etc.) 
  • Care Coordination (facilitate communication between providers, appointment making, transportation, specialty visits
  • Patient Education and Activation
  • Community Resources (to identify, refer and access care for Members)
  • No PCP visit in 6 months