Program Description
Provider Type
- Participating Physician Groups (PPG)
The Health Net care management program integrates the care management process, eliminates duplication of services between Health Net and its participating physician groups (PPGs), and facilitates communication and cooperation between Health Net, PPGs and members.
Health Net case managers, or delegated PPGs, assure that potential medically catastrophic cases are managed in cooperation with the member's primary care physician (PCP) to achieve optimum care and coverage benefits for the member. Case managers provide assistance by working with members, caregivers, physicians, and other members of the care team.
The following criteria are used for case management:
- Lack of an established or ineffective treatment plan – for example, a member with multiple providers and multiple services who continues to use the emergency room or continues to have multiple admissions for the same conditions.
- Over-, under- or inappropriate utilization of services – for example, a member who inappropriately over-utilizes emergency room services, or who does not have an established PCP or specialty care provider, when appropriate.
- Permanent or temporary alteration of functional status – for example, a member with a hip replacement who is discharged with no home support or is unable to get to medical appointments and/or physical therapy.
- Medical/psychosocial/functional complications – for example, an elderly member with multiple medical conditions (comorbidity) and depression who is unable to manage activities of daily living, medications and diet.
- Barriers to receiving appropriate care within the system – for example, a newly diagnosed cancer patient who has been educated by coaches, but who would also benefit from coordination of care services through Health Net's case management.
- Nonadherence to treatment or medication regimens, or missed appointments – for example, a member with transportation needs who is unable to get to physician appointments, or who has transportation or financial barriers to filling medication prescriptions.
- Compromised patient safety – for example, an elderly member, post hip replacement, who lives on the second floor requires home evaluation for safety concerns.
- High-cost injury or illness – for example, a member in a severe motor vehicle accident with multiple injuries would require coordination of and authorization for multiple services for an extended period of time.
- Lack of family or social support – for example, a post-operative member with wound care, but without family support to assist with dressing needs.
- Lack of financial resources to meet health needs – for example, a member requiring extensive wound vacuum services but who has exhausted benefits, or a senior member who needs transportation, home help or other noncovered items.
- Exhaustion of benefits – for example, a member with medical necessity for a specialized hospital bed, but the member's durable medical equipment (DME) benefit is exhausted.
Health Net case management functions operate according to Case Management Society of America standards.
Assessment
Assessment is the first step in the care management process. The Health Net care management team gathers information to assess the member's care gaps and needs. Information may include health risk assessment results, medical records and interviews with the member and health care team. The care manager utilizes the results of the assessment to develop a care management plan in collaboration with the member, or their designated representative, to address care needs. For additional information, refer to Case Management at PPG > Initial Assessment and Ongoing Management.
Evaluation and Monitoring
The care management process continually evaluates quality of care, efficiency of services and cost-effectiveness. Monitoring occurs at:
- Plan level - oversight of the member's care through periodic reviews of health status and needs, evaluation of satisfaction with and use of services, and reports on the ongoing savings of disease-specific care
- Member level - review of clinical status and problems, communication with the physician and other members of the health care team, and use of satisfaction surveys
Implementation
Actions are taken to address the care needs identified in the assessment process and documented in the care management plan. The implementation of these actions includes working with the member's PPG to provide the needed services, referring members to community services or advocating provision of informal services by family and friends. The care manager supports the physician's plan of care through continually monitoring and finding new available resources.
Planning
Successful planning involves a multi-disciplinary approach developed by the provider and the care manager. This may include disciplines from both internal and key external parties, because each brings a unique perspective. Planning can occur formally in a care conference or informally through working individually with other providers. A care plan may be limited to arranging temporary home care after a hospital discharge or it may serve to integrate long-term health care, social services and informal care.