Care Management Program

The Care1st Care Management Program is a collaboration between Care Managers (registered nurses or licensed behavioral health professionals), members and providers, which plans, implements, coordinates, monitors and evaluates options and services to meet the members’ health care needs. The Care Management Program specifically addresses the needs of the members with complex medical or social conditions, high utilization, high costs, special needs, or high-risk conditions. The focus is on assisting members to use medical, social, or community resources effectively to maximize their quality of life.

Care Management Program will identify, support and engage our most vulnerable members at any point in the health care continuum and help them achieve improved health status. The goal is to decrease fragmentation of healthcare service delivery, to facilitate appropriate utilization of available resources, and to optimize member outcomes through education, care coordination and advocacy services for the medically compromised populations served. The program integrates medical, behavioral, and socioeconomic assistance to members by facilitating assessment of risk and health needs, coordination of care/benefits, service delivery, community resources, and education. Care Management Program will provide for continuity of care, transition of care, and coordination of care or services for all members’ needs in an integrated and member-centric fashion.

Our objectives include:

• Increasing member engagement with the PCP and PCP-referred specialists
• Increasing member understanding and use of plan benefits
• Increasing member awareness of community resources available to help improve their quality of life
• Increasing members understanding of diseases/conditions
• Decreasing unnecessary emergency room utilization
• Decreasing unnecessary hospital visits and admissions
• Encouraging members to self-manage their conditions effectively and develop and sustain behaviors that may improve the member’s quality of life
• Optimizing member’s health outcomes

Care Management Program is available to all members. Potential candidates for Care Management Program include, but are not limited to the following:

• Members with complex, chronic or co-morbid conditions such COPD,CHF, CAD, Diabetes, Asthma, HIV/AIDS, depression
• Members discharged home from acute inpatient or SNF with multiple services and coordination need
• Members requiring care coordination
• High utilizes of services such as pharmacy or emergency departments (either by cost or volume)
• Special populations (e.g., aged, blind, disabled, HIV-positive, substance abusers, pregnant women, special needs children, members with behavioral health needs)