Care Management

Complex care

The Complex Care program is a collaborative initiative that engages a multidisciplinary care team consisting of management staff, contracted physicians, and providers including contracted network hospitals and other relevant stakeholders (community services, home care, durable medical equipment, behavioral health, etc.). The program includes collaboration with acute care hospitals, nursing, social services, medical staff, pharmacy, emergency and quality departments. The program focuses on patients identified through a combination of claims data and referrals from providers, members, and caregivers.

Program goals

• Improve care coordination for patients across care settings.
• Optimize chronic care management.
• Educate patients about diagnoses and self-management.
• Implement care plans for high risk members and members with complex care needs.
• Improve medication compliance.
• Address member/caregiver needs regarding adequate support and resources at home.
• Improve adherence to the hospital discharge care plan for patients discharged to home.
• Decrease “avoidable” utilization events, such as readmissions.

Transition care

The Transition Care program provides members with tools to help them get and stay well during the critical period after a hospital admission. The goal is to decrease their chances of returning for readmission to the hospital after they have been discharged.

Program goals

Eligible members prioritized for outreach receive a personalized transition care advisor who works closely with the member and their care team (both inpatient and ambulatory). The care advisor’s main objectives are to:

• Proactively identify members who are at high risk for readmission based on clinical, social, and psychological/behavioral factors.
• Educate members on their conditions and potential pitfalls.
• Review the member’s discharge plan and identify potential barriers.
• Ensure appropriate post-discharge follow-up.
• Make sure care is coordinated after discharge between primary care providers, specialists, and others (home health, infusion, etc.).
• When appropriate, conduct basic medication reconciliation, sometimes in conjunction with clinical pharmacy services.
• Develop a post-discharge plan of care which includes contingency planning in case the member develops new or worsening symptoms.

Behavioral health care

The program takes an enrollee-centered approach to care and collaboration between the multidisciplinary team, including the PCP. This ensures the enrollee receives the appropriate care interventions and level of motivational and emotional support that aligns with their readiness for behavior change. Specifically, this behavior change refers to behavioral and physical health needs, lifestyle risks, personal preferences and goals, and psychosocial, cultural, and educational needs.

Program goals

Eligible members prioritized for outreach receive a personalized transition care advisor who works closely with the member and their care team (both inpatient and ambulatory). The care advisor’s main objectives are to:

• Support enrollees in achieving optimal behavioral health, everyday functioning, and improved quality of life.
• Support enrollees in overcoming barriers to treatment and recovery.
• Prevent behavioral health condition related exacerbations and complications.