A Comprehensive Case Management Program

Case management services were available to all eligible members and few individuals declined these services. Physicians in the health plan network were notified of the program at the time it was implemented via an article in the physician newsletter sent out by the health plan.

Case managers reached out by telephone to identified members and conducted a comprehensive assessment of their needs and developed individual plans of care that addressed the members’ stablished with the member”caregiver during the initial outreach.

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The case manager assisted the member and family by addressing issues such as the need for education of the disease process for member and familrcaregiver, understanding of advanced directives and assistance with obtaining these documents, understanding their preferences for care, identifying community resources for member and caregiver support, social work support, pain control, medication management, and home or respite care. The case manager worked with the member’s physician to coordinate care and with the hospice agency if hospice was in place.

The case manager handled an average caseload of 40-45 health plan members, all in various stages of need for support. Members with advanced illness made up a small percentage of that caseload at any given time.

The internal cost for a nurse case manager to manage a member with advanced illness was approximately $400. In January 2005, a pilot program was launched for 13 large employers whereby, in addition to the provision for case management support, insurance benefits for hospice and respite were expanded.