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The Complex Case Management program supports participating members in a variety of care settings, going beyond traditional medical and preventive services.

Using medical, pharmacy and health claims information, upon referral by care providers, or occurance of an event like hospital admission, at risk members are identified, enrolled and directed to programs and services to help improve and maximize their care. Through the use of coordinated systems and advanced software, Case Managers are able to identify members in need, and provide education and care coordination to assist them in obtaining needed treatment while removing barriers to service.

Goals of the Complex Case Management Program Includes:

  • Assist in coordination of physician’s treatment plan, consistent with the member’s benefits

  • Reduce the member’s hospital admissions and readmissions for preventable treatment and disease complications

  • Verify that a workable discharge plan is in place for the member
  • Encourage discharge plan adherence

  • Help improve the member’s overall satisfaction with his/her health care

  • Refer members to the appropriate Care Management/Disease Management program(s)

Complex Case Management

The Complex Case Management program provides access to specialized nurses and other resources (dietitian, clinical pharmacists, behavioral therapists) that can assist in better managing a enrolled member’s health and coordinate their health care needs. By collaborating with members and their physicians, or other healthcare professionals, our the case management team is able to facilitate access to healthcare services and provide support for health-related decisions, ensuring members obtain the highest quality of care, maximize their health care coverage, and save money.

Members are generally enrolled in the program upon a referral from their care provider or by the TPA.

The program uses a standardized case management process for all of its assigned members and consists of several key areas including but not limited to:

  • Comprehensive Initial Assessment of member’s health

  • Development of an individualized care plan

  • Facilitation of member referrals to resources
  • Follow-up and communication with members

  • Self-Management Plans

  • Assessment of progress against case management plans for members

When a member is identified for these programs, he or she is assessed to determine the appropriate level of intervention. A Registered Nurse, acting as the member’s Case Manager, will contact the member by phone to explain the program details and assist with enrollment. Case Managers maintain at least monthly contact to address and meet varying member needs.

Generally, case managers provide the following to members enrolled in the program:

  • Support adherence to care plans to improve health complexities

  • Advocacy to ensure appropriate services and resources are received

  • Education and promotion of self-management in order to empower members to take a more active role in their health

  • Coordinated and seamless integration of complex services and/or special needs
  • Appropriate and timely communication with members, practitioners, and hospitals

  • Systematic approach to assessing, planning and provision of case management services to improve health outcomes

  • Referrals to appropriate medical, behavioral, social and community resources to address member needs

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