Care Management Programs
These programs help to ensure members receive the right medical treatment at the right time.
The result is more efficient care delivery, more appropriate utilization, and fewer gaps in care.
This program focuses on select chronic conditions, identifying members who are at moderate-to-high risk based medical and pharmacy claims. These members work telephonically with a condition management nurse to develop a plan that teaches them techniques for self-managing their condition. Members also receive condition-specific education and reminders about important screenings.
Our integrated Behavioral Health Program helps ensure seamless service delivery, leaving no gaps in care. Licensed clinicians work collaboratively with our case managers, with everyone accessing a shared clinical record with a single view of each member. And we make sure access barriers are removed so members don’t need a referral from a Primary Care Provider (PCP) to see a behavioral health care provider and on non-saver plans, we have simple, low co-pays.
Substance Use Disorder Treatment + Recovery
One example of this integrated approach is our substance use disorder program. When a member is admitted for detox, our clinicians work with the facility to ensure the full spectrum of needs are addressed for that member, including any co-occurring conditions. Upon discharge our behavioral health clinicians review the discharge plans with the member and work on a follow-up program that tracks to evidence-based best practices. Research shows that using an evidence-based approach results in an average 60% success rate—2.5 times the industry average, with only a 10-12% relapse rate.
We are proud to say that we have a 50% engagement rate in this program, far exceeding the industry average that’s closer to 20%.
Substance Use Disorder Family Navigator
Responding to the opioid epidemic in 2016, we created the position of substance use disorder navigator. This clinically trained professional helps members and their families understand addiction, treatment options, benefits and the health care system. The navigator can:
- Offer information on providers, treatment programs, and community programs
- Answer any questions the member and family may have about the condition, and
- Help coordinate available resources
Members with a cancer diagnosis receive personalized outreach from nurse care managers in our oncology program. Our nurses understand the challenges of chemotherapy and can help our members take steps to help reduce the impact of treatment.