Complex care program chooses participants
Screening identifies patients who will benefit most
BlueCross BlueShield of South Carolina members who participate in the Franklin Health Complex Care Program, administered by Upper Saddle River, NJ-based Franklin Health, are chosen carefully through a process that identifies patients who will benefit most from the service.
"We look at the whole patient, the psychosocial issues, their home situation, comorbidities, history of admissions, and a lot of different things, as well as their condition and their treatment. If they are reacting well to their treatment, have a good support system, and are educated about their treatment options, they’ll probably be managed through the health plan’s case management system that’s already in place," says Michelle Hendershot, account director for Franklin Health.
Here’s how the program works:
BlueCross BlueShield of South Carolina identifies patients who may be eligible for the program through pre-certification. Often patients are referred by the insurer’s case managers or utilization managers, or through referrals from providers.
"The local oncologists are very familiar with the program and will refer patients they know need the service," says Catherine Beatty, RN, MSN, manager, medical services for BlueCross BlueShield of South Carolina.
When patients are suggested for the program, BlueCross BlueShield of South Carolina does an initial screening to make sure they are eligible for the program under their insurance plan.
Then the insurer’s case managers call the patients to see if they are interested in participating.
Franklin Health’s care coordination team then reviews the clinical situation to make sure it’s an appropriate case. If the patient is appropriate and interested, the Franklin care manager talks to him or her on the telephone to further explore whether services are needed.
For instance, patients typically are not put into the program if they have a good treatment plan in place and a good relationship with their providers, or if they are at a stage when they don’t need an intervention yet. The Franklin care managers also take psychosocial needs and family dynamics into consideration and include patients who need a lot of support.
The nurse care manager goes to the patient’s home, hospital room, or rehab center and conducts an initial assessment, looking at medical history, current condition, family, and living environment.
The team members (the care manager, the clinical account manager, and the physician) use the information to identify issues and set goals, then confirm the plan with the treating physician.
The Franklin care managers coordinate the care for the patients in the program, working closely with the BlueCross BlueShield case managers.
The health plan case managers work out the best way to use the benefits under the plan. The Franklin care managers may help find additional resources for things that are not covered by the health plan.
Although many of the patients in the complex care program are terminally ill, others progress to the point that they no longer need intensive care management.
In those cases, the Franklin care managers work closely with the insurance case managers as they turn the case over to them.
"Working with BlueCross BlueShield of South Carolina is a wonderful example of teamwork and collaboration. The patients are very complex and need to be managed intensely. When those who are not terminally ill do return to a state where they can be managed by the health plan’s case manager, there is a lot of collaboration in the hand-off between the case managers. They work together to make sure the members get what they need," says Jeanne Clement, RN, MPH, senior vice president of operations for Franklin Health.
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