Complex Case Management Program

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 utilizes 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

Members are selected for this program when they have a significant, life-limiting diagnosis with multiple comorbid conditions and critical barriers to their care. Many of these members have diagnoses that are no longer responding to typical treatment regimens or are unable to participate in aggressive treatment without additional support. Complex case management manages members who are experiencing acute and severe events, such as:

• Complex chronic conditions such as diabetes, asthma, chronic obstructive pulmonary disease (COPD), and vascular or active cancers.
• Multiple co-morbidities.
• A health event that has the potential for significant consumption of resources - (medical or financial).
• Complications relating to frail health status.
• Those experiencing frequent or prolonged hospitalizations or emergency visits.
• Multiple psychosocial factors, such as need for support system, transportation, financial resources, decision support, habilitation, or residential needs.
• Functional impairment, such as dependency for activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
• Individuals who are eligible by law, such as those with mental or developmental 'disabilities.

Program Components

This program helps facilitate an appropriate personalized level of care for members, which includes:

• Telephonic and face-to-face (as needed) interactions with a trained nurse 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.