Care Management at PPG

Provider Type

Participating Physician Groups (PPG)

The following information is not applicable to Dual Special Need Plans.

Health Net members who are experiencing catastrophic and chronic injuries or illnesses are evaluated for care management services. Health Net delegated participating physician groups (PPGs) can use a variety of population data sources to identify members for care management, including, but not limited to:

Data collected through utilization management (UM) processes, such as prior authorization and concurrent review
Hospital admission data
Hospital discharge data
Claims and encounter data
Pharmacy data

In addition to data identification, the care management program must have multiple avenues for members to be referred for care management services. This includes discharge planner referral, UM or concurrent review referral, member self-referral, and practitioner referral.

Care Management Vendors

For some conditions, ancillary providers contracting with Health Net to provide services can provide member care management related to those conditions. For specific ancillary provider information, contact the Health Net Care Management Department.

Initial Assessment and Ongoing Management

The care management process should be problem-focused and address risks. Goals should be actionable and address the member's needs. Documentation, typically kept in a care plan, needs to define issues, problems and appropriate interventions, and include follow-up evaluations. The care manager must document that the member was contacted and notified of their right to decline or disenroll from care management services.

The care management process must consider all of the following elements:

Initial assessments of members' health status, including condition-specific issues
Documentation of clinical history, including medications
Initial assessment of activities of daily living (ADLs)
Initial assessment of behavioral health status, including cognitive functioning
Initial assessment of life-planning activities
Evaluation of cultural and linguistic needs, preferences or limitations
Evaluation of caregiver resources and involvement
Evaluation of available benefits within the organization and from community resources
Development of care management plan with prioritized goals that consider the member and care-givers' preferences and desired level of involvement in the care plan
Identification of barriers to meeting goals or complying with the plan
Development of a schedule for follow-up and communication
Development and communication of self-management plans
Process to assess progress in care management plans
Evaluation of visual and hearing needs and limitations
Facilitation of member referrals to resources and follow-up process to determine whether the members act on referrals

In addition, Health Net may request feedback on members referred by the health plan to the PPG for care management screening.

Providing Tools to Care Managers

To assist care managers in monitoring cases, Health Net can provide PPGs with forms, tracking tools and information on how to access community resources for its members. Care management must be evidence-based and the systems and processes to support care management should use algorithmic logic, such as scripts or other prompts to guide care managers through the assessment and ongoing management of members.

Health Net care managers and provider service specialists can assist PPGs in obtaining tools and information necessary to direct Health Net members through the care continuum.

PPG Screening Criteria

Health Net members who meet the following criteria should be screened for care management services:

Members with multiple admissions (two or more hospitalizations) within six months
Members with multiple emergency room (ER) visits (three or more), or two hospital admissions, for the same condition within six months
Members with multiple ER visits (five or more) for multiple conditions within six months
Members who are eligible for public health programs
Members who are accepted into clinical trials
Pregnant members with high-risk conditions who require home health services
Members identified through the health risk questionnaire process
Members referred from Health Net's Care Management Department

For additional information, refer to Care Management Program Description.

Note: All Health Net Special Needs Plan (SNP) members are assigned a care manager; therefore, screening to meet specific criteria for program participation is not necessary.

To achieve the goals of the Health Net care management program, Health Net monitors care management processes to ensure there is no duplication of efforts between Health Net and participating physician groups (PPGs).

In some instances, the PPG or associated hospital has direct responsibility for specific tasks, such as authorization of professional services and on-site concurrent review. Other tasks are Health Net's responsibility, such as education of various key parties in the care management of members. Where shared responsibilities occur, communication between Health Net and the PPG becomes especially vital in ensuring that each operates as efficiently as possible.

Health Net Care Management Responsibilities

Health Net is responsible for the following care management activities when the PPG completes the member's care management functions:

Provide oversight as required by regulatory agencies, such as the California Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS), and by accrediting entities, such as the National Committee for Quality Assurance (NCQA)
Inform referral source of member's participation in the Health Net care management program
Notify the provider that the member is assigned to the Health Net care management program
Review the proposed plan of care with a Health Net regional medical director, as requested or indicated based on established processes
Encourage providers and members to take responsibility for implementation of the care plan
Monitor progress and service provided to the member
Offer suggestions for revisions to the care plan to meet the changing health care needs of the member
Serve as a source of information for the availability and costs of community resources within each geographic area
Participate in meetings at hospitals, skilled nursing facilities (SNFs) and home health agencies as indicated when they pertain to member care management
Evaluate the services provided and, with the provider and member, determine when the member should be discharged from the Health Net care management program (not applicable for SNP)
Incorporate disease management into the care management program, as appropriate

PPG Care Management Responsibilities

The PPG is responsible for the following care management activities:

Utilize the Health Net designated care management program for members who meet guidelines, such as state management and transplants
Provide care management program activities meeting Health Net and regulatory standards
Provide treatment and member-care documentation to Health Net when requested
Participate in Health Net's care management program evaluation activities when requested by Health Net
Provide feedback to Health Net on members referred by Health Net to the PPG for care management

The Health Net prospective care management process begins with identification of at-risk members. Throughout this phase of the program, multiple modalities are used to evaluate the member's clinical and psychosocial status. Some of these modalities include health risk assessments, wellness programs, preventive measures, and evaluation of Healthcare Effectiveness Data and Information Set (HEDIS^®) and risk management information. Identification and intervention is integrated with disease management programs.

Health Net's care managers collaborate with a team of Health Net medical directors, the primary care physician (PCP) and participating physician group (PPG) staff to coordinate identification and arrangement of care, the care plan, evaluation of the effectiveness of the care plan, and communication with the interdisciplinary team during all phases of treatment.