care management department overview of the care … · developed by the: alliance training &...

Developed by the: ALLIANCE TRAINING & DEVELOPMENT DEPARTMENT

Knowledge when you need it!

Slide 1

Overview of the Care Management Department

Time Commitment: 12 minutes

Audio

Hello and welcome to an overview of the Alliance’s Care Management Department. This presentation will take twelve minutes. You can pause the presentation at any time, and click on the menu button to view previous slides to view previous slides or the Resource Button to download a copy of this presentation.

Care Management Department An Overview Presentation

Overview of the Care Management Department of 28

Central California Alliance for Health Training & Development Department

Slide 2

What is Care Management?

Care Management Department =

Case Management Unit

Health Programs Unit

+

+

In this presentation we will discuss how our Care Management department works. You may be asking yourself, ‘what is care management?’ Care management is comprised of two distinct units, case management and health education.



Slide 3

+

Care Management



We will be going over two main sections – the health programs unit, and the case management unit – which we will discuss in further detail. But first, let’s delve into our definition of care management.



Slide 4

Care Management Department partners with…

Care Management Department

…to better manage the health needs of our population.

members providers

and

+

Care management partners with both members and providers to better manage the health needs of our members.



Slide 5

Collaborative

approach that:

1. Facilitates

2. Educates

3. Links

4. Supports

Goals of Care Management Department

+

Care management uses a collaborative approach with four main goals. The first goal is to facilitate relationships between primary care providers and members. Second, is to educate members on navigating the healthcare system. Third, is to link members to available community resources. And lastly, care management aims to support member’s self-management efforts. We will discuss some of these ideas in greater detail.



Slide 6

Results:

Better health,

lower cost,

better care.

Complex Case

Management

Care Coordination

Disease Management

Prevention

Care Management Department

+

The Care Management department has two units: Health Education, which supports prevention and disease management, and Case Management which supports complex case management and care coordination. Our goals are aligned with the Institute for Healthcare Improvement (IHI) triple aim initiative. The IHI triple aim initiative is a framework for optimizing health system performance and greatly impacting improved population health. The results of using this framework leads to: better health, lower cost, and as a result…better health care.



Slide 7

+

Care Management



Now that you have an overview of the Care Management department, let’s discuss the health program’s unit.



Slide 8


Healthy Moms & Healthy Babies

Healthy Breathing for Life Healthier Living Workshop Healthy Weight for Life

Tobacco Cessation Support Avoidable ED Visits Live Better with Diabetes Cultural & Linguistic Services

8 Distinct Programs for DiseaseManagement & Prevention

The Health Programs Unit contains eight distinct programs for disease management and prevention. These programs are: Healthy Moms & Healthy Babies, Healthy Breathing for Life, Healthier Living Workshop, Healthy Weight for Life, Tobacco Cessation Support, Avoidable Emergency Department Visits, Live Better with Diabetes and the Cultural & Linguistic Services. These programs partner members with experienced staff, who use evidence based guidelines and motivational interviewing techniques. All of our programs are state reviewed and approved. Let’s take a closer look at each of these eight unique programs.



Slide 9

Member Incentive: $25 Target gift card


& Healthy BabiesWhat we do…

Healthy Moms

Postpartum CareMember must see PCMH within 21-56 days following delivery

Breastfeeding support services

+

Early Prenatal CareMember must see Patient Centered Medical Home (PCMH) within first 12 weeks of pregnancy or within 42 days of becoming a member

The Healthy Moms & Healthy Babies program consists of two initiatives: early prenatal care and postpartum care. The early prenatal care program is designed to encourage pregnant women to seek early prenatal care during their 1st trimester or within 42 days of becoming a member. In the postpartum care program the member must have a postpartum visit within twenty one to fifty six days following the delivery of their baby. Additionally, we also offer breastfeeding support services. To increase member engagement in these services, a $25 Target gift card is offered as an incentive in each program.



Slide 10

Telephonic outreach to high risk

members to assess asthma self-management and discuss Asthma Action Plans (AAPs)


Healthy Breathing for Life (HBL)

What we do

Connect members to Asthma

Clinical Health Education benefit and local community resources

Member IncentiveMonthly Raffle for a chance to win $50 raffle if PCMH returns completed AAP

+

Our Healthy Breathing for Life program works with members within the ages of five through 64. The intervention utilizes several methods to connect with and engage members. We use telephonic outreach to high risk members to assess asthma self-management and discuss Asthma Action Plans (APPs). An Asthma Action Plan helps people learn how to manage their asthma, and also what to do in the event of an asthma emergency. We also connect members to Asthma Health Education benefits and local community resources. As a member incentive, we offer a monthly raffle where participating members have a chance to win $50 if their PCP returns a completed Asthma Action Plan.



Slide 11

Facilitate workshops using Stanford’s Chronic Disease Self-Management Program (CDSMP)

2½ hours per week for 6 weeks

Encourages participant’s self-confidence in their ability to manage their chronic health condition(s)


Healthier Living Workshop

What we do

+

The Healthier Living Program uses Stanford’s Chronic Disease Self-Management Program (CDSMP). CDSMP is designed to help members, 18 years of age or older, gain self-confidence in their ability to control their symptoms and how their health problems affect their lives. The highly interactive workshops are six weeks long, meeting once a week for 2 ½ hours, and are facilitated by a pair of Alliance leaders one or both of whom are non-health professionals with a chronic disease themselves.



Slide 12

Members who follow this Program have an average healthcare cost savings of 590 dollars annually

Fewer inpatient and outpatient emergency department visits

Improvement in patients ability to participate in one’s own care over a two-year period

Improvement in 7 of 9 variables


Healthier Living Workshop

Does it work?

Member IncentiveMembers who complete all 6 classes will

receive a $25 gift card

+

You may be asking yourself, so how do we know that the CDSMP works? Well, studies indicate that members who follow this Program have an average healthcare cost savings of 590 dollars annually, including fewer inpatient and outpatient emergency department visits. Studies also show an improvement in patients ability to participate in one’s own care over a two-year period. Members showed improvement in 7 of 9 variables including, fatigue, shortness of breath, pain, social activity limitation, illness intrusiveness, depression and health distress. Additionally, participants showed healthier behaviors and self-efficacy related to exercise, cognitive symptom management, and communication with physicians. As an incentive, members who complete all six workshops receive a $25 gift card.



Slide 13

5210 Campaign Telephonic outreach and education to high risk members


Healthy Weight for Life (HWL)

What we do

Member Incentives

• Up to $50 in gift cards for reducing Body

Mass Index (BMI) percentile points by 3+ points

• Bicycle raffles

Health education materials are mailed to low to medium risk members

+

The Healthy Weight for Life program uses several outreach strategies to increase member engagement. The 5210 Campaign utilizes telephonic outreach as well as education to high risk members. Health education materials are also mailed to low to medium risk members. Member incentives include up to $50 in gift cards for reducing body mass index percentile by three or more points, as well entry into a bicycle raffle.



Slide 14


Tobacco CessationSupport (TCS)

Education on Alliance and local

tobacco cessation services and medications available to members

What we do

Members are also referredto the California Smokers’ Helpline

+

The Tobacco Cessation Support program focuses on educating its members on Alliance and local tobacco cessation services as well as medications that are currently available. We aim to connect members to the California Smokers’ Helpline – 1-800-NO-BUTTS – or local tobacco cessation classes. The helpline offers free counseling over the phone in English, Spanish, and other languages.



Slide 15


Telephonic outreach on

appropriate ED use

What we do

Provide copy of the book

“What to Do When your Child Gets Sick” with questionnaire

Member IncentiveMembers are entered into a raffle for a

chance to win a $50 gift card

Avoidable Emergency Department Visits

+

The Avoidable ED Visits program uses telephonic outreach to educate the parents of members on appropriate emergency department use. Additionally, we provide a copy of “What to do When your Child Gets Sick” with a completed questionnaire. This book helps parents differentiate between when to call 911 or use emergency services versus when to contact their doctor. We also do a monthly raffle with a chance to win a $50 gift card if a member returns a completed questionnaire that is mailed with the book.



Slide 16


Telephonic outreach to members

21 years of age and older

Educate members on the importance

of specific diabetes screenings

Live Better with Diabetes

What we do

Connect members to Diabetes

Clinical Health Education benefit & local community resources

Member IncentiveMembers who complete certain

screenings receive a $50 gift card+

The Live Better with Diabetes program focuses on helping members keep their diabetes under control. We use telephonic outreach to adult members to educate them on diabetes self-management. Members are encouraged to work their Patience Centered Medical home to get specific diabetes screenings. We also connect members to Diabetes Clinical Health Education provider and local community resources. A $50 gift card is provided as incentive for completing the following diabetes screenings: A1c, cholesterol, eye exam and medical attention for nephropathy.



Slide 17

Health Programs

Cultural & Linguistic Services

Language Assistance• Telephonic interpreting

• Face to Face Interpreting (for special situations)

• American Sign Language

What we do

Interpreting services available to

our members 24/7 for all covered services

Written materials in English,

Spanish and Hmong

+

Our Cultural & Linguistic Services Program offers various forms of assistance for our members. With an increasingly culturally and linguistically diverse group of members, it is important to provide appropriately matched healthcare. We offer several language assistance services, including telephonic interpreting, face to face and American Sign Language interpreting services. Additionally, we offer written materials in English, Spanish, and Hmong.



Slide 18

+

Care Management



Now that we’ve covered the programs offered by our Health Programs Unit, let’s take a closer look at the Case Management Unit.



Slide 19


Partner with primary care provider (PCP) and patient centered medical home (PCMH) to improve health outcomes

TEAM:PCP’s, Nurses, Social Workers, and Care Coordinators, and Beacon Case Management

+

The focus of the Case Management Unit is on handling complex cases. The main goal of our team is to partner with primary care providers and the patient centered medical home to improve health outcomes of our members. This team includes the primary care provider, nurses, social workers, care coordinators and integrated mental health services by Beacon case managers. The team assists members in establishing a relationship with the PCP, links members to community resources, and helps them with mental health services. Our team works both telephonically and in-person, which is dependent upon the members individualized needs.



Slide 20


PCP & PCMH

…provide basic + complexcase management to…

Alliance members

…partners with the PCP & PCMH to support members

Alliance Complex Case Management Team PCP & PCMH

Includes intense coordination of resources from the multidisciplinary team to ensure the member regains optimal health or improved functionality.

+

Primary Care Providers (PCPs) provide basic and complex case management to Alliance members. The Complex Case Management team partners with the PCP and PCMH’s to supports members in managing their acute or chronic illness. This may include intense coordination of resources from the multidisciplinary team to ensure the member regains optimal health or improved functionality. Individualized person centered care plans are created with the involvement of the PCP and member. The support may include services that address emotional, physical and social support needs.



Slide 21


Complex Case Management Activities:

1

.

2

.

3

.

4

.

5

.

6

.

Comprehensive Assessment

Promote relationshipwith PCP and PCMH

Care Coordination

Promote Self-Management through Engagement

Connect to Community and Social Support Services

Follow: up to 6 Months

+

To further understand complex case management, let’s discuss some of the activities associated with it. Complex case management provides comprehensive assessment, promotes relationships with the primary care provider and/or the patient centered medical home, uses care coordination, promotes self-management through engagement, connects members to the community and social support services, and follows up with members for up to 6 months.



Slide 22


6 Steps to Complex Case Management Process

1. 2. 3.

6. 5. 4.

Assessment Work with member and

PCMH

Develop a care plan

Coordinate careReassessment & monitoring

Graduate!

+

Let’s talk about the 6 step complex case management process. First, comes assessment of the member, then working with member and PCMH, then developing a personalized care plan, then coordinating care, then reassessment and monitoring of the member and finally graduating!



Slide 23

Case Management

Chronic Illness Catastrophic Diagnosis Medical Issues

Types of Referrals to Complex Case Management Program

• Poorly controlled chronic illness obesity/ bariatric patients

• Medication reconciliation• Multiple admissions (excludes

cancer)• Palliative care

• Complex injuries • HIV/AIDS (new diagnosis &

unlinked)• End of life

• Complicated wounds • Stroke with complications• New or worsening debilitating

disease (I.E. Multiple sclerosis, parkinson’s)

• Seizure disorder with complications

+

What kind of member is a good fit for the complex case management program? Some appropriate referrals may include anyone with chronic illness, such as poorly controlled chronic illness or new and or worsening complications, obesity/ bariatric patients, medication reconciliation, multiple admissions - excluding cancer - and palliative care. Another good fit would be anyone with a catastrophic diagnosis which includes complex injuries, HIV and AIDS, and an end of life diagnosis. Other examples of appropriate referrals to the complex case management program include anyone with medical issues such as complicated wounds, stroke with complications, new or worsening debilitating disease, and seizure disorder with complications.



Slide 24

Case Management

Other health coverage

(OHC) members

Disruptive, violent, or

abusive behaviors

Members who are

unable to be reached

Members who refuse

to participate

What is not an ideal referral to complex case management?

+

Some members are not a good fit for complex case management. So, what is not ideal for referral to complex case management? This would include members with Other Health Coverage (OHC) as a primary insurance, members who have disruptive, violent, or abusive behaviors, members who are unable to be reached, and members who refuse to participate.



Slide 25

Case Management

Care Coordination Social Work Program Children’s Case Management

• Complex durable medical equipment (DME) requests

• Assistance with referrals• Complex transportation needs• Outreach & engagement

• Psycho-social assessment • Address social determinants

of health

• Children with special health needs

• Developmental disability• High risk infant follow-up• Complex therapy requests• (CCS) California Children's

services coordination

Not a good fit for Complex Case Management?We provide other services!

+

Even if you’re not a good fit for complex case management, we offer a variety of other services that may be more appropriate as well. Specifically, we have three main programs which include care coordination, our social work program, and children’s case management. Care coordination includes complex durable medical equipment (DME) requests, assistance with referrals, complex transportation needs and outreach and engagement. The social work program includes psycho-social assessments and addresses social determinants of health, such as finances, legal, housing, food, education and respite care. Our children’s case management program includes assistance with children who have special health needs, developmental disabilities, high risk infant follow-up, complex therapy requests and California Children’s Services (CCS) coordination. As part of our services, we also coordinate follow up visits. Subsequently, members can receive help at any time. As part of our services, we also coordinate follow up visits. Subsequently, members can receive help at any time.



Slide 26

Complex Case Management 1-800-700-3874 ext. 5512

Health Programs 1-800-700-3874 ext. 5580

Beacon (Mental Health Services)

1-855-765-9700

Beacon ASD Line 1-855- 834-5654

Care Management Referral Lines

+

We accept referrals from providers and members during normal business hours Monday through Friday 8am to 5pm. You can also contact these lines if you have questions: Case Management at 1-800-700-3874 ext. 5512, Health Programs at 1-800-700-3874 ext. 5580, Beacon Mental Health Services at 1-855-765-9700, and Beacon ASD line at 1-855- 834-5654



Slide 27

Overview of the Care Management Department

In partnership with:

THE ALLIANCE TRAINING & DEVELOPMENT DEPARTMENT

Knowledge when you need it!

Thank you for viewing our overview of the Care Management Department, which was developed in partnership with the Alliance’s Training & Development Department.



Slide 28

Further Questions?

Case Management Line1-800-700-3874 ext. 5512

If you have further questions about any of the material presented, please contact our Care Management Director, Liza Warren at 831-430-5780.

care management department overview of the care … · developed by the: alliance training &...

Documents