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Complex Care Management

/Complex Care Management
Complex Care Management2018-10-04T16:08:32+00:00

Complex Care Management

Goals and Objectives

The goal of the program is to help members regain optimum health or improved functional capacity in the right setting, utilizing the right providers, in the right time frame and in a cost-effective manner. It involves a comprehensive assessment of a Member’s condition, to include but not limited to, determination of the available benefits and resources, and development and implementation of a Care Management Plan with performance goals, monitoring, and follow-up. More specifically, the goals established for the Complex Care Management (CCM) Program include:

• Improving the quality of life for Members
• Improving functional capacity of Members
• Increasing Member self-care
• Improving efficiency by reducing unnecessary emergency department visits and hospital utilization
• Enhancing access to appropriate health care resources

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Referral to Care Management

Referrals to Complex Care Management may be made by:

  • Members or Caregivers
  • Providers
  • Practitioners
  • Discharge Planners

To Make a Referral:

Download the GOBHI Care Management referral form
Or call 1-800-493-0040 or 541-298-2101 and ask for the Care Management Team.

The following criteria are used to determine which Members will benefit from the CCM Program. Program criteria were established to provide the opportunity to participate in Complex Care Management for Members with a variety of complex conditions.

Factors distinguishing Complex Care Management typically include a degree of complexity of illness or condition that are severe, requiring a level of management that is intensive and requiring an extensive amount of resources to obtain optimal health or improved functioning. Eligibility will start the date the Member is identified as being eligible for CCM services. Enrollment occurs when the Member has provided consent to receive services.

CCM is a voluntary program, so only Members who agree and consent to the program are enrolled.

CCM Program eligibility criteria are two pronged – Risk factors and Complex social needs.

Members may have medical complexity that is compounded by related psychosocial, and/or behavioral health needs.

Members with the following risks:

  • Severe and persistent mental illness
  • Complex medical issues and/or comorbidities
  • Poorly controlled disease states
  • At least one Emergency Department (ED) visit in the past 6 months or
  • At least one inpatient admission in the past 6 months

AND one or more of the following needs:

  • Adherence to treatment (medications, visits, behavior change, diet etc.)
  • Care Coordination (facilitate communication between providers, appointment making, transportation, specialty visits)
  • Patient Education and Activation
  • Community Resources (to identify, refer and access care for Members)

Transitional Age Youth (ages 17-19)

Members with the following risks:

  • Severe and persistent mental illness
  • Poorly controlled disease states
  • Taking prescribed medications for behavioral health needs
  • At least one ED visit, inpatient admission, State hospital admission or residential treatment in the past 6 months

AND one or more of the following needs:

  • Adherence to treatment (medications, visits, behavior change, diet etc.)
  • Care Coordination (facilitate communication between providers, appointment making, transportation, specialty visits, assistance with transitioning from Child/Adolescent MH services to Adult Services)
  • Patient Education and Activation
  • Community Resources (to identify, refer and access care for Members)

The Complex Care Management Program is voluntary and is provided at no cost to the Member. A Member must give verbal and/or written consent for enrollment in this program. The program is most successful with participation of the Member’s family, caregivers and/or other support systems.

The CCM Program will use a standardized Care Management process for all of its assigned Members which consists of several key areas, including but not limited to:

  • Comprehensive Initial Assessment of Member’s health
  • Development of an individualized care plan
  • Facilitation of member referrals to resources
  • Follow-up and communication with Members
  • Self-Management Plans
  • Assessment of progress against Care Management plans for members

Care Managers provide ongoing care management for as long as the Member has identified needs and expresses willingness to receive support and services from the program.

Generally, Care Managers provide the following to all Members enrolled in the program:

  • Support Member adherence to care plans to improve health complexities
  • Advocacy to ensure appropriate services and resources are received
  • Education and promotion of self-management in order to empower Members to take a more active role in their health
  • Coordinated and seamless integration of complex services and/or special needs
  • Appropriate and timely communication with Members, practitioners, and hospitals systematic approach to assessing, planning and provision of Care Management services to improve health outcomes
  • Referrals to appropriate medical, behavioral, social and community resources to address Member needs
  • Phones and/or replacement phone minutes to replace those used in the Care Management process

The Complex Care Management Program uses a customizable care management software platform which provides software tools, data analytics and support services to help streamline clinical and administrative processes. Those features include but are not limited to:

  • Risk Stratification and Predictive Modeling: An integrated predictive modeling engine using imbedded algorithms driven by evidenced-based guidelines and diagnosis-based risk methodology to automatically stratify patients by level of severity
  • Identifying Care Gaps: More than 300 clinical care, behavioral health and medication-related evidence-based indicators to help identify gaps and other opportunities to improve member health
  • Up-to-date Care Management Framework: Superior clinical content based on the Milliman Care Guidelines are updated annually to effectively guide the daily workflow of clinical staff

Specifically, the CCM Program uses a client-centric, holistic approach, encourages self-determination and self-care, integrates behavioral change science and principles, links with community resources and assists with navigating the health care system –within the framework of cultural competence and professional excellence.

The program also promotes quality outcomes and has established periodic assessments to measure and track the outcomes. The roles of the Complex Care Managers are consistent with those outlined in the guidelines: assessment, care planning, communication and coordination, education, empowering and advocacy.

The program also follows the Care Management process detailed in the guidelines: Member identification and selection, assessment and problem/opportunity identification, development of care plan, implementation of interventions, and evaluation of progress and termination of the Care management process.

Adapted from Denver Health Medical Plan, Inc. Complex Care Management Program Description