Care Coordination (CC) assists members and their families with complex needs

Care is member-centered, family-focused, and culturally competent.

CC assists in locating services to meet the health and social needs of the member.

The CC team is comprised of Medical and Behavioral Health Clinicians and Health Coordinators

Collaboratively with the member, Medical CC, Behavioral Health CC and the inter-disciplinary care team (ICT) develop a plan of care.

The ICT may include a variety of professionals: Natural supports

Family members

Community members

Medical and Behavioral Health Providers

Importance of early alerts is essential to reduce crisis

Communication is a key to success!

Care Coordination helps ensure the member’s needs are identified and addressed: The identified CC is members’ single point of

contact

Coordinating care with members and locating providers to meet their needs

Assisting with coordination of medical and behavioral health services;

Health Risk Assessment (HRA) Telephonic HRA 30 days of their

enrollment during transition (Steady State HRA’s will be initiated within 10 days)

Stratification of medical and social risk

Low (Level 1)

Wellness and education

Telephonic outreach

Ongoing monitoring for continued need

Moderate (Level 2) or High (Level 3)

Comprehensive Needs Assessment (CNA)

Telephonic and Face to Face Communication

Coordination of needed services

Communication with ICT

The Comprehensive Needs Assessment (CNA) Face to Face In home setting if at all possible The CNA is collaborative effort which might

include: Member’s, providers, School, Homemakers,

families, in home and out of home services and others that are part of the Member’s life

A new CNA will be completed if there is a change in member status Series of questions that identify areas of

need CNA helps develop a Care Plan to address

identified needs LTSS the Care Plan must be approved by the

BCBSNM LTSS UR department.

PCP’s and Members will have a copy of their care plan

Care Coordination Details

Contact the member on an ongoing basis Telephonically

Face to Face .

Communicate with PCP’s, and other members of the ICT team on an ongoing basis.

Reassessments as required or whenever the member’s needs have changed.

Communication with Providers and community agencies are important for success.

Native American Options Native American Care Coordinators

are available upon request. If a Native American Care

Coordinator is not available, a Community Health Worker will be present for all in-person meetings with you and a non-Native American Care Coordinator. Blue Cross Community Centennial

facilitates a language translation service called “Language Line”. The provider's staff will need to contact customer service and request this service at 1-866-689-1523.

Concerns that would prompt outreach to CC Concerned that a patient is not

medication compliant Death in family Unaddressed Medical/Behavioral issues Untreated substance abuse needs Disengagement Social Concerns Concerns regarding Self Directed

Community Benefits For questions regarding the Care

Coordination services, contact Case Management Programs at

1-888-349-3706.

Medically/Behaviorally Complex

Members will be assigned a Complex Care Coordinator Those in need of Transplants

Those with Co-Occurring needs

High Risk pregnancies

Frequent ER visits

Care Coordination and Early Intervention (CCEI)

Goal: To decrease readmission rates and avoidable ER visits

Proactive CC for High Risk surgical procedures.

Longitudinal CC

Members with chronic conditions that are not stable and/or complex social issues

Complex Care Coordinator

Assist medical CC with complex cases.

Independently licensed clinicians who are board Certified Case Managers.

For questions regarding the BCBSNM Community Care Coordination services, contact Case Management Programs at 1-888-349-3706.

Blue Cross Community Centennial Care offers a variety of disease management programs for our members.

These Include :

• Diabetes • Metabolic Syndrome • Cardiac Clusters • Musculoskeletal

Leading Indicators (includes Low Back Pain)

• COPD - Chronic Obstructive Pulmonary Disorder

• CHF – Congestive Heart Failure

• CAD ( Coronary Artery Disease)

• Depression • Alcohol/Substance

abuse disorders • Anxiety/panic

disorders • Bipolar disorders • Eating disorders • Schizophrenia and

other psychotic disorders

• Special Beginnings Maternity Program

Condition Management

Automatically enrolled.

Can opt out Receive mailings pertinent to their

condition(s) and care gap outreach.

Access to Emmi Solutions and Care on Target programs and tools.

The 24/7 Nurse Advice line also has hundreds of recorded wellness sessions that can be accessed. 24/7 Nurseline 800-973-6329.

CareKits for chronic conditions.

Outreach from a nurse or social worker.

Condition Management services from their Care Coordinator if appropriate.

If needed CC will facilitate intensive Condition Management services.

Examples of this type of provider would be: A Community Health Worker

A Certified Diabetes Educator

A Patient Centered Medical Home who offers classes

A Senior Center who offers classes

PCP- Lock in

Utilization of unnecessary and duplicative services

PCP or attending physician, must approve PCP lock-in for the member.

The PCP can request a PCP lock-in for a member who is seeing multiple providers for the same services.

A PCP lock-in can be done for more than one provider if indicated.

Pharmacy Lock-In

Utilizing more than one pharmacy when prescription non-compliance

Drug-seeking behavior is identified or suspected.

The PCP can request a pharmacy lock-in

The BCBSNM Case Manager, pharmacist and medical director jointly monitor the members who are in the PCP/pharmacy lock-in process,

Coordinate with the PCP and the pharmacy

Report on these members quarterly to HSD.

Community Social Services Program

Identify community resources for the Members in need, for example: Access to food bank resources for

members.

Connect with housing and transportation resources.

Identify local resources so members are able to access services locally from people that know their language, customs, and history.

Connecting with the Provider One or Social Service Program when: A patient is in need of social assistance.

Need help finding a specialist for a patient referral.

Need assistance in locating community resources for their patients.

Communicating with the Care Coordinator:

Providers will receive a copy of the Care Plan with the name of the Member’s Care Coordinator with his or her direct phone line.