How Our Care Managers Make a Difference for Members
Tufts Health Plan helps members with serious or chronic medical needs navigate their care
One of the most important ways Tufts Health Plan helps members with serious or chronic medical needs navigate their care, save money and get better outcomes is through our robust care management program. And at the heart of that program are our care managers.
Most of our Care Managers are nurses or, in the case of a behavioral health care manager, clinical social workers. They bring an unmatched combination of knowledge, compassion and commitment to help members with specific conditions like high-risk pregnancy, cancer, diabetes, heart disease, HIV/AIDS or behavioral health issues. Some of these conditions come with elevated risk for complications related to COVID-19, which makes the work of our care managers that much more vital at this moment.
We sat down with two of our Care Managers, Sharon Soucy and Marcella Poulin, to get a closer look at their work with members.
In a nutshell, what do you see as your primary role as a Care Manager?
Marcella: A big part of our job is helping the members navigate the healthcare system. We often talk to members who are just getting home from the hospital, or have a brand-new diagnosis, or are still trying to figure out what their diagnosis is, and they don't know which way is up. So, to get a phone call from a care manager to help them start figuring out where to start, which appointments to set up and what questions to ask, can be extremely helpful to members.
Sharon: Right. We're not giving medical advice, but we have that medical perspective so we can help them to understand what things mean or what they’ve been told, be it medication or diet or anything else. Typically, one of the first things I tell people is to bring a notebook to appointments so they can write things down. We just want to help them be a little more proactive and prepared when they're going into appointments.
Marcella: I’d add that our care management isn’t really based on what we want. It's based on what the member wants. Part of our job is empowering them to self-manage and be their own advocate when they walk into the medical office.
What other resources are you able to connect members with?
Sharon: Sometimes we tap into other resources that we have within Tufts Health Plan. We have a behavioral health department here that we work very closely with and will consult with them or refer members there if they needed help. Those psychosocial issues can cause barriers on the medical side.
The current COVID-19 (coronavirus) outbreak presents a new health concern for many of our members. How have you and other care managers responded to the crisis?
Sharon: We have been proactively calling members within high risk groups as well as enrolled members in our programs. It’s important now more than ever that we outreach our members, ensuring they have support, where they can find resources and how we can help with the burden during this unprecedented time.
Marcella: Guiding members to reputable resources such as the CDC for information can be helpful, particularly at a time of media overload. We can assist members in improving their knowledge of the facts, recognizing when to call their providers, and understanding what resources are available to help support them through this tough time. Aside from the medical aspect, reminding members and their families the importance of self-care, physically and mentally, through difficult situations like this goes a long way.
How does care management help members reduce their healthcare costs?
Marcella: Reducing hospital re-admissions is a big one. Our outreach calls for transition to home, to make sure members have the right support for home care, follow up visits, medication management, etc. We also help keep people in-network. We’re not going to refer them someplace where they're going to get a surprise bill.
Sharon: Sometimes we’re able to help with pharmacy needs, too, reviewing whether there are other, cheaper options for a member’s medication.
Last question: What do you find most rewarding about your job?
Marcella: I love talking to all of these different personalities and trying to find a way to connect with a member so I can help them reach their health goals. We're not going to be able to solve every problem, but even a small success is still a success and it means a lot to me and to Tufts Health Plan and to the member.
Sharon: What I enjoy most is being a partner for someone who is going through probably a pretty difficult time—helping them find the confidence within themselves to be able to manage some of these barriers that they might otherwise feel alone in facing. With us, they know they have a partner in Tufts Health Plan.