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Plan Info

Complex case management

The Complex Case Management Program actively assists our sickest members with coordinating proper care. Members are identified for complex case management using a stratification tool that identifies members with selected medical conditions and key claims-based health risk factors. Quarterly, the members are assigned a risk score. Based on the results, members targeted are those who have an actionable risk and are likely to be affected by case management. Identification of and outreach to complex members involves: 

  • Comprehensive assessment of member needs and barriers
  • Review of discharge instruction
  • Coordination of home care services
  • Coordination of community resources and behavioral health resources
  • Assistance with durable medical equipment
  • Assistance with medication delivery
  • Assistance with transportation
  • Coordination of PCP and specialist appointments 

Smoking cessation facilitators are available to help members quit smoking and dietary counseling to help members achieve their optimal nutritional status.  The goal of the program is to identify any barriers to care and alleviate those barriers, establish member-centered goals and achieve the highest level of self-management possible. Referrals can be made to this program by calling 1-866-500-4571.