Evaluate to determine who will benefit from CM
Examine claims data, current situation
When a member is referred into the case management program at Blue Cross Blue Shield of Arizona, the case managers do a triage evaluation to determine which members are likely to benefit from case management interventions.
They examine the historical claims data and the current situation, and decide whether case management can have an impact.
"This is a critical issue. Sometimes, you can’t have an impact because of the significance of the disease. If this is the case, and a member is using their benefits appropriately, our interventions would not have an impact," says Barbara Guerriero, RN, MA, vice president of medical services.
If the members are appropriate for the case management program and consent to participate, the case manager does a full assessment that includes physical, psychosocial, and behavioral evaluations.
The case managers develop the care plan with the provider, the member and/or family, and come up with long-term and short-term goals based on the findings in the assessment.
"We work within the benefits structure to meet the goals and adjust the plan when it’s necessary," Guerriero says. They look for psychosocial issues, cultural diversity impact, need for family support, long-term care planning, and the various venues of care in case of a patient with traumatic injuries.
There are two Spanish-speaking case managers on staff who work with the Hispanic population.
"We know that multiple trauma patients often need active rehabilitation, then skilled nursing care, and then home health. We want to make sure we are part of the process to guide the member through it," she says.
The care managers update the care plan regularly and set criteria for discharging patients from case management as their goals are met.
Chronically ill members are referred to the insurer’s disease management program, depending on their individual needs. For instance, patients with diabetes who are at the lowest risk levels receive ongoing educational materials. Those with the highest risk level are assessed for entry into the case management program.
At present, members in the case management system are assigned alphabetically by name to a case manager. The company set up a case manager "buddy system" so each case manager has a specific backup person to cover for them. There is a centralized database for all documentation, making it easy for the "buddy" to fill in for an absent case manager.
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