2. Integrated Care Model Case Management:
Member centric - One case manager approach to all member care needs
integrated care model (incorporates behavioral, medical and social)
Utilizes CORE and Predictive Pathways Modeling (PPM) to identify and stratify member Embeds CM in large practice facilities
Incorporates onsite NICU CM, face-to-face for highest level of care members as well as telephonic outreach
Focus :
top utilization and highest risk
ED utilization
Hospital readmission
High risk disease management
Neonatal Abstinence (NAS)
Hepatitis C

3. What is CORE

6. Sr. Director Field Service Coordination, Kentucky Market
Care Management
Shannon Jones RN,CCM
Sr. Director Field Service Coordination, Kentucky Market
WellCare Health Plans

7. Essentials Of WellCare’s Enhanced Care Model
WellCare’s enhanced model of care:
Identifies members with high, impactable needs who can benefit most from care management.
Uses trusted evidence-based guidelines to drive Clinical & Quality of Care interventions.
Addresses our members’ complex needs using a high touch community-based approach to promote their optimal health and wellness.
We leverage community resources to act as a bridge between the formal health care system and the members we serve.

8. WellCare’s Care Management Model
The Care Model rests on the foundation of an integrated case and disease management philosophy, enabling holistic care of the individual.
The Care Model facilitates seamless delivery of care and services, care management, utilization management, and quality care. Medical and behavioral health are aligned under this structure.
The Care Model acknowledges that healthcare is delivered locally and solutions must also consider the member’s community resources, personal healthcare, social determinants, and cultural ecosystem.

9. Care Management: Identify Members
REACH
ENGAGE
ACCESS
CARE
HELP
Predictive Modeling &
Early Intervention
Chronic Care
Management
(Most Vulnerable Population)
Acute Care
Management
Value Drivers
Operating Principles / Features
Clinical Controls
HRA, Algorithms, Census, etc.
Local Deployment
Field interdisciplinary care management teams
Efficient Allocation of Clinical Resources
Targeted use of face-to-face visits in concert with chronic, acute and condition management interventions
Early Intervention
Use of care managers embedded at the point of care
Impactable Conditions
Quality Metrics
Financial Stewardship

10. Engaging our Members
IDENTIFY
REACH
ENGAGE
ACCESS
CARE
HELP
Focused geographic staff assignments to synergize market expertise (CM/BH/SW/UM).
Discharge planning nurses provide transitional interventions and monitor length of stay at facilities with a high daily census.
Innovative outreach and education strategies.
Incentive programs for rewarding engagement in health and wellness activities.

11. Access & Care for our Members
IDENTIFY
REACH
ENGAGE
ACCESS
CARE
HELP
Member
Care Coordination & Provider Engagement
Community & Social Safety Net Resources
Primary Care, EPSDT & Wellness Services
Medical & Behavioral Health Services
Community-Based
Services
Medical Management
CLINICAL CARE MANAGEMENT
BUSINESS & QUALITY MANAGEMENT
BENEFIT COORDINATION
COMMUNITY CARE MANAGEMENT 11
Property of WellCare Health Plans, Inc.

12. Clinical Programs COPD Transitions of Care Asthma High-Risk Obstetrics
IDENTIFY
REACH
ENGAGE
ACCESS
CARE
HELP
COPD
Transitions of Care
Asthma
High-Risk Obstetrics
Substance Abuse
Obesity
Foster Care
Emergency Department

13. Kentucky Field Service Coordination List-Physical Health
Terri Flanigan
Vice President, Field Health Services
Cell
Shannon Jones
Sr. Director, Field Service Coordination
Cell
Region 5 and 7
Paula Franklin, Manager
Cell
Ashland Office
Lexington Office
Region 3 and 6
Donna Chapman, Manager
Cell
Louisville Office
Region 8
Leeann Caudill, Manager
Cell
Hazard Office
Region 1, 2 and 4
Trudy Smyth, Sr. Manager
Bowling Green & Owensboro
Cell
BG Office
Owensboro Office

14. Kentucky Field Service Coordination List-Behavioral Health
Vice President, Field Health Services
Terri Flanigan
Cell
Sr. Director of Product Operations
Lori Gordon
Cell
Behavioral Health Program Manager
Kate Miller
Cell  
Sr. Manager, Foster Care, Adoption & Guardianship
Leann Magre
Cell  

15. Your Connection to Disease and Case Management Programs
Care Coordination
Your Connection to Disease and Case Management Programs
Robert Beaty, RCP, RRT-ACCS, AE-C, BA
Team Lead, Care Coordination
Passport Health Plan

16. What is Care Coordination?

17. Purpose
To improve the health status and quality of life of members, while decreasing unnecessary hospitalizations and emergency room (ER) visits, by improving member self-management skills, and by increasing adherence of both members and providers with clinician adherence with national guidelines.

18. Onsite Programs
ER Navigator
Tiny Tots
Discharge Education Team
Stork Care
Embedded Case Management
The ER Navigators and ER Coordinators are working to reduce these numbers by educating our members on proper ER utilization and the programs and services available here at Passport to assist them with their health care needs.
The ER Navigators are the nurses in the ER making face-to-face contact with the members, giving them information on the programs and services available to them in an effort to reduce the non-emergent ER utilization. Passport kids are not subject to ER lock in
The ER Coordinators receive daily (Norton and Sts. Mary and Elizabeth) or weekly (Hardin Memorial) reports on ER utilization of Passport members and use telephonic outreach and mailings to educate members on proper ER utilization and refer them to the appropriate programs/departments to assist them with any barriers to care.
Tiny Tots One in nine babies born in the United States are premature
Almost two-thirds of all childhood hospital stays are for newborns (babies up to 30 days old)
Goal:
Ensure a secure and healthy transition of the detained newborn from hospital to home
Identify detained newborns and primary caregiver at point of initial hospitalization
Provide early education regarding care of medically fragile infant
Coordinate a safe transition to home
Assist in arranging discharge needs when medically stable
Identify gaps in care
Ensure adherence to after care instructions
Ensure adherence to scheduled physician appointments
Ensure appropriate interventions are followed
Definitions:
Detained Newborn: Infant in the first 28 days of life that remained hospitalized after mother was discharged.
Discharge
The goal of our program is to reach out to our members in person while they are in the hospital. We provide education in certain disease categories, currently we are concentrating on CHF, COPD, Respiratory, AMI, Diabetes and Chronic Illness and look for barriers they may have to receiving care. We are sometimes asked by hospital staff to visit members with other conditions that might benefit from our help and we are always happy to do so

19. Programs at Passport Disease Management Complex Case Management
Behavioral Health Case Management
Foster Care/Adoption Guardianship Liaison
Mommy Steps
Specialty Programs

20. Process Case Manager Technician
Rapid Response Case Manager/Embedded Case Manager*
Appropriate Program
*Pregnant, Medically Fragile, etc.

21. Value
2015 when compared to 2014
297% increase in Health Risk Assessments
13,003 24/7 RN hotline calls
37% increase
88% referred to Lower Level of Care
95% in agreement
ER, IP, and Readmit representative of members in CM

22. How to refer to Care Coordination
content/uploads/2015/01/2-cc-care-coordination- request-form.pdf
Rapid Response
Fax