Complex Case Management Program
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Ancillary
The Complex Case Management program identifies members as being at high risk for hospitalizations or poor outcomes and who have barriers to their health care. The program uses an evidence-based, approach, which is member-focused and goal-directed, in developing, implementing and monitoring the care plan. Trained nurse care managers, in collaboration with a multidisciplinary team, provide coordination, education and support to the member in achieving optimal health, enhancing quality of life and accessing appropriate services.
This program supports the member, family and caregivers by coordinating care and facilitating communication between health care providers. Once a member is selected to participate in the program, a case manager contacts the member's provider to coordinate care.
Outcomes for this program include:
- Completion of a comprehensive health assessment that identifies medical needs (including primary and specialty care), medication management, durable medical equipment (DME) needs, and other psychological and social needs.
- Collaboration between the case manager, member (family and caregiver), multidisciplinary team, primary care physician (PCP), and other clinical providers to develop an individual written plan of care that is communicated to the provider and medical home.
- Coordination of care, including provision of emotional and social support, for acute and chronic illness.
- Improved member knowledge of their illnesses, self-management skills, health care options, and available services.
- Avoidance of unnecessary emergency visits and hospitalizations, seamless transitions between levels of care and the appropriate use of resources.
On an ongoing basis, Health Net evaluates the efficacy of this program by reviewing and comparing specific member outcomes and utilization before and after case management intervention.
Criteria
The Plan uses the Population Health Management (PHM) report to identify members for Complex Care Management. The PHM report combines data from multiple sources to use in its population and program eligibility process. Data elements from multiple sources are stored in corporate-wide data warehouses. Data from the warehouse is extracted into a predictive modeling tool, Impact Pro. The data is pulled from the main data warehouse into the risk stratification tool housed in Impact Pro: medical and behavioral claims/encounters, pharmacy claims, laboratory results, health appraisal results, electronic health records, data from Plan utilization management (UM) and/or care management (CM) programs and advanced data sources such as all-payer claims databases or regional health information. Members are stratified into one of 10 Population Health Categories in Impact Pro: Level 01: Healthy to Level 10: End of Life. In addition to Impact Pro, a web-based customizable report-generating system, MicroStrategy, is used to produce adjunctive analytical reports for related PHM programs including Complex Care Management.
Members stratified as described below are identified as complex and are referred to care management.
Diagnostic categories typically associated with high intensity of services and/or high cost but are generally well managed in the individual. Diagnoses include, but are not limited to:
- HIV/AIDS
- Cancer.
- Asthma with associated inpatient admission.
- Sickle cell.
- Congestive heart failure.
- Depression.
- Anxiety.
- Children with special health care needs.
- Other state-mandated criteria such as members under 21 years of age receiving private duty nursing services.
- Members otherwise meeting criteria for Complex Care Management but who do not have an additional parameter such as ER likelihood: high
- Members who reach a designated score based on responses to the Screening HRA and/or who requested an ICP or individualized care team may be referred to Care Management.
- Primarily social determinants of health such as housing, financial, etc. with need for referrals to community resources.
- Need for assistance with accessing health care services related to continuity of care.
- Participation in county program requiring supplemental Plan support.
Program Components
This program helps facilitate an appropriate personalized level of care for members, which includes:
- Telephonic interactions with a trained nurse or social worker case manager.
- Comprehensive assessment of medical, psychosocial, medication adherence, and DME needs.
- Development of an individual care treatment plan reflects the member's ongoing health care needs, abilities and preferences.
- Consolidation of treatment plans from multiple providers into a single plan of care, to avoid fragmented or duplicative care.
- Coordination of treatment plans for acute or chronic illness, including emotional and social support issues.
- Coordination of resources to promote the member's optimal health or improved functionality with referrals to other team members or programs, as appropriate.
- Education and information about medical conditions and self-management skills, compliance with the medical plan of care, and other available services to reduce readmissions and inappropriate utilization of hospital services
- Communication to the provider and medical home.
Referrals
Providers may refer members for complex case management and complete the Care Management Referral Form – Health Net (PDF), Care Management Referral Form – Community Health Plan of Imperial Valley (PDF) or Care Management Referral Form –CalViva Health (PDF). Members may self-refer to the program by calling the member services telephone number on the back of their identification (ID) card.