PAM Section 6: Case Management

On this page:

• Overview
• Transitions of Care Program
• Disease Management Program
• Behavioral Health Program
• Chronic Care Improvement Program – Congestive Heart Failure
• CHF Telemonitoring Program (CHF)
• Nurse Advice Line
• Complex Case Management Program

Overview

Our case managers are available to assist our members by coordinating services for easy access to medical care through a variety of services, such as:

• Health and Wellness Referral.
• Complex Case Management.
• Behavioral Health.
• Transition of Care.
• Disease Management.

Case managers are also in charge of administering the Centers for Medicare & Medicaid Services (CMS) required programs such as:

• Chronic Condition Improvement Program – Congestive Heart Failure.

Mount Carmel MediGold Health Plan’s knowledgeable and caring case managers provide education and medical and emotional support for members. They refer members to health and wellness resources in their community. For members who are “high risk,” they collaborate with a treatment team to create member-specific, cost-effective health care options to share with the member and their family. Targeted members may have chronic conditions such as chronic obstructive pulmonary disease, congestive heart failure, diabetes or an acute illness requiring coordination of multiple services, short-term intensive intervention or long-term education and monitoring. The goal of case management is to facilitate maximum functional levels at the most appropriate intensity of service.

Case management is conducted by telephone and includes a needs assessment, development of a care management plan, on-going monitoring and case closure. All case management program processes are documented in standardized formats and closely coordinated with aspects of utilization management, including prior authorization and concurrent review.

If you identify a member who is at risk for high utilization of services or who needs assistance in coordinating health care services, please submit a Case Management Referral Form.

Transitions of Care Program

Our program is focused on evaluating and coordinating post-hospitalization needs for members who may be at risk of readmission. Mount Carmel MediGold Health Plan case managers are involved with care transitions, such as discharge from an inpatient hospital admission to home or a skilled nursing home discharge to home. The Case Manager will outreach these members and complete an assessment, medication reconciliation, and update the member’s care plan as needed.

Disease Management Program

The goal of our DM program is to improve the member’s quality of life by helping them better manage and monitor their chronic disease through the development of a collaborative treatment plan with their primary care provider.

We work with members to help with their chronic conditions and how to monitor those by developing a treatment plan in coordination with their primary care provider.

1. Condition monitoring: Work with the member to ensure they are monitoring their conditions, e.g., getting labs done and medication adherence.
2. Medical behavior comorbidities and other health conditions: Coordination of care as they are generally delivered by multiple providers and may include other medical and behavioral conditions.
3. Health behaviors: The DM program content addresses health behaviors that may impede a member’s ability to manage a condition and encourage members to develop healthy behaviors.
4. Psychosocial issues: This program addresses psychosocial issues that may be barriers for the member in meeting treatment goals and identifies how the program modifies interventions to address the issues that arise from:
   • Cultural, religious and ethnic beliefs concerning the condition of treatment options.
   • Perceived barriers to meeting treatment requirements.
   • Education.
   • Access, transportation and financial barriers to obtaining treatment.

Behavioral Health Program

Our program offers services provided by a Licensed Independent Social Worker. Services included but not limited to referrals to inpatient facilities, outpatient providers and community support groups. Our program will start with a thorough psychosocial assessment and followed by a plan of care development that it is individualized to meet the needs of our members. Included in these services are psychosocial support, resources linkage and behavioral health education at no cost to our members.

Chronic Condition Improvement Program – Congestive Heart Failure

Congestive heart failure (CHF) is a very common condition with approximately 6.5 million people who live with it in the United States. There are different types of Congestive Heart Failure (CHF), left sided and right sided. Symptoms include shortness of breath and fluid buildup in your body. Heart Failure (HF) is progressive, it starts slowly and progresses over time. There is no cure for Congestive Heart Failure, however, it can be managed with a combination of medications and lifestyle changes.

Mount Carmel MediGold Health Plan has established the following goals as measures of success for the program:

• Enhance member self-management skills through education, Case Management coaching and written material.
• Increase number of members using appropriate medications
• Increase number of members correctly using medications
• Establish and maintain communication with Primary Care Provider (PCP) and Specialist Providers
• Reduce the number of inpatient admissions and Emergency Department (ED) utilization
• Decrease length of stay when hospitalized
• Reduce morbidity and mortality

CHF Telemonitoring Program (CHF)

This program focuses on helping members with a diagnosis of Congestive Heart Failure and who qualify with linkage to the Home Care Connect Virtual Monitoring Program. Mount Carmel MediGold Health Plan works with the Home Care Connect Program and Vivify in order to ensure that members who participate in the program receive monitoring for a sixty day or longer time period based off of the members need. Once enrolled, the member is advised on how to set up their kit and provided with directions on how monitoring works. Case Management stays involved during this time to provide any support to the member that is needed.

Nurse Advice Line

Expert answers to your health care questions are just a phone call away, with the Mount Carmel MediGold Health Plan 24­-Hour Nurse Advice Line. Registered nurses are available 24/7 to answer your questions, assess your symptoms and help you decide whether you should call your doctor, head to the urgent care or treat your symptoms at home.

Complex Case Management Program

Mount Carmel MediGold Health Plan aims to take care of members who have experienced a critical event or diagnosis that requires extensive use of resources. They may need help navigating the system to facilitate appropriate delivery of care and services. This program goes beyond providing case management for one complex condition, e.g., transplant member or members already enrolled in Mount Carmel MediGold Health Plan disease management programs. The scope of services provided by complex case manager to the members include:

• Initial assessment of health status.
• Education about the case management program.
• Development of a member-specific care plan with goals, task, barriers, opportunities and self-management skills.
• Reassessment of progress against the member care plans and evaluation of adherence.
• Based on acuity, regularly scheduled contact with the case manager.
• Assistance in navigating and collaborating with practitioners and community resources regarding treatment.
• Supporting transitional care between inpatient to other facilities or home.
• Discussion with interdisciplinary team to review treatment plan and interventions.

Last updated: 03/2024