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Case Management Programs

The case management program assumes responsibility for the coordination of all aspects of care for members identified with chronic or high-risk conditions. This includes high-risk maternity, palliative, chronic kidney disease, behavioral health, oncology, HIV/AIDS, and members awaiting a transplant. The role of the case manager is to promote quality care and meet the member’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting.

Chronic Kidney Disease

The target audience for this program includes members with chronic kidney disease in slowing the progression of their illness through member education and coordination with a nephrologist. Targeted interventions are offered for different stages of illness and care managers work with primary care physicians to encourage nephrologist referrals for appropriate members.

Right Start Prenatal Program

The emphasis of this maternity and newborn care program is to promote full-term births among participants. Right Start assumes responsibility for the coordination of all aspects of care for pregnant members identified as high-risk.

The case manager follows the member throughout the pregnancy. The role of the case manager is to promote quality care and meet members’ needs while maximizing benefits and assuring proper use of services in the most appropriate setting. The program uses New York State Department of Health Medicaid prenatal guidelines in an effort to standardize and improve prenatal care.

Palliative Care

The palliative care program is designed for members with an end-stage illness who are not ready to enter hospice. The program has a dedicated case manager to interact with members, their families, and their health care providers to assist members in achieving their goals during a difficult time.

Transplant

The case management and utilization management teams work collaboratively to improve care for transplant candidates. Targeting providers from centers of excellence for increased interaction and early identification of potential candidates has resulted in increased member satisfaction and quality care.

HIV/AIDS

Our HIV/AIDS case management program’s goal is to promote adequate and timely care, manage comorbid conditions, adhere to medications and treatment plans, and address high-risk behaviors to prevent the spread of infection. Linking proper care, support services, and home care promotes improved outcomes.

Obstructive Sleep Apnea

Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes such as weight loss and avoiding alcohol before bedtime may decrease the severity of the apnea. Positive airway pressure (PAP) therapy often is the best treatment for moderate to severe obstructive sleep apnea. Other treatments such as oral appliances, surgery, and breathing devices (CPAP, BiPAP, etc.) may be required to effectively manage the disorder. Our respiratory therapists call members and assist them in adapting to their therapy.

Behavioral Health Case Management

A specialized staff of licensed behavioral health clinicians provides behavioral health case management services to members with significant mental health and/or substance use disorders. Diagnoses include major depressive disorder, substance abuse, psychosis, and bipolar disorders, in addition to risk for suicide. This specialized team facilitates linkages between behavioral health treatment providers (e.g., counselor, psychiatrist, and psychologist), primary care providers, and other needed treatment providers.

Through close follow-up with members, continued treatment adherence and support group utilization is encouraged. Due to the high comorbidity of behavioral health and chronic medical conditions, the Behavioral Health Case Management and Medical Case Management teams collaborate to ensure continuity of care.

Oncology Case Management

The oncology case management program provides members and their families with education, support, and advocacy. Case managers assist members in coordinating necessary health care services, while maximizing health care benefits. The case managers act as a resource for information, community resources, and care options and assist with the transition to palliative/hospice care, when appropriate. Oncology case management has demonstrated positive outcomes for better control of the patient’s conditions and completion of treatment regimen, along with reduction in length of stay and potential complications.