Case Management and Chronic Disease Management Will Save the Employer Group Tens of Thousands of Dollars in Avoidable Admissions, Re-Admissions and Emergency Room Visits.
Case Management
Case Management, simply stated, is a medical management process where a medical professional, registered nurse, medical social worker, behavioral / mental health specialist, nutritionalist; or in some cases, a physician, work directly with a patient or group of patients who have a chronic illness in order to assist the patients understanding of their medical problem and the treatment prescribed by their physician. This poorly utilized service saves the employer group an average $11.00 for every $1.00 invested. There exists specific nationally recognized criteria that define if a patient should be case managed. Those nationally accepted criteria can be found at multiple sources to include the National Association of Certified Case Management or Utilization Review Accreditation Commission (URAC).
Integrated HealthCare Management, LLC (IHM) utilizes a unique model where the case manager engages the patient and sees them primarily in their (the patient’s) home environment. The goal of IHM is to educate the patient about their chronic disease, acute illness or injury to direct them on how to be compliant with all aspects of their prescribed treatment thus facilitating the best possible medical outcome for the patient.
Statistics indicate that case managed patients have better medical outcomes, are admitted or re-admitted fewer times, are pharmaceutically compliant and more productive on their jobs.
The cost of care for case managed patients approximates 20% versus those patients not case managed but who met the criteria to be case managed.
Chronic Disease Management
The goal of the Chronic Disease Management program will be to support the Patient Centered Medical Home (PCMH) in its efforts to manage the individual needs and challenges of any member with a chronic disease. Working closely with the Third Party Administrator (TPA), Integrated Plans will review adjudicated claims data in addition to evaluating current health histories completed by the participating members and their dependents.
Once identified these members will be referred to the Patient Centered Medical Home (PCMH) where their physicians and nurses will design and implement a chronic disease management program suitable to each members.
Typically, the following conditions are evaluated:
- Chronic Pulmonary Diseases – Smoking cessation programs, medication management and inhalation therapy, and Oxygen therapy management
- Diabetes – Proper testing and follow-up and a nutrition consult
- Asthma – Proper treatment and follow-up
- Coronary Artery Disease – Screening and treatment including follow-up
- Congestive Hear Failure – Performing tasks of daily living
- Women’s Health – Screening through Papanicolaou (Pap) Testing, Breast exams, and Mammograms
- Immunizations – Assure that timely immunizations are complete
- Auto Immune Diseases – Medical management
- Patients diagnosed with Cancer and those patients in remission will be closely evaluated
Chronic Disease Management Process
The data from the claims payor is evaluated for health indications and costs that relate to the above conditions in concert with the health information forms the member will be asked to complete. There will be health status issues that will be identified by the patient’s Primary Care Physician (PCP), or other health status issues that may arise.
Chronic Disease Management Patient Approval
Each identified Plan Member must agree to participate in a Health Management Program
Chronic Disease Management Primary Care
For those Plan Members linked to a Patient Centered Medical Home (PCMH) by virtue of their choice of the provider as their Primary Care Provider (PCP) or through assignment by the medical benefit management team if the member does not exercise that choice the Integrated Plans chronic disease management staff will play a coordinating role to ensure the patient understands that our nurses are always available to them. For these patients, Integrated Plans will always defer to the PCMH disease managed program.