Care Management and Disease Management

We provide programs for members with chronic and complex medical and behavioral health conditions, and those with socioeconomic barriers. Our goal is to help members and their providers better deal with their conditions, follow prescribed treatment plans, and prevent additional complications. 

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. 

If a member agrees to participate in any of our Care Management programs, a care manager will notify you by letter or telephone and work to coordinate your patient’s care.

Complex Care Management

Complex Care Management targets the most complex, highest risk members, including those with special health care needs for which a multidisciplinary approach is utilized:
Medical conditions that may be appropriate for a care management referral include, but are not limited to:

• Cancer
• Bariatric Surgery
• HIV
• 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