Menu Bottom

Transition of Care Management

Program Description

This program is designed specifically to coordinate and manage the care of medically complex patients, recently discharged from hospital, to prevent re-admissions and/or frequent emergency room visits. The Transition of Care Management Program arranges medical care for patients within the first 30 days of discharge.

The benefits of the program include reducing risk for:

  • hospital admissions/complications secondary to treatment side effects
  • hospitalization secondary to complications related to co-morbidities
  • hospitalization secondary to non-compliance with medications and post-discharge instructions
  • hospitalization secondary worsening of primary medical conditions managed during recent hospitalization

The CMC Transition of Care Program includes the following coordinated services:

  • home care
  • home intravenous infusion
  • physician office visits
  • home care physician visits
  • durable medical equipment delivery
  • medications reconciliation and compliance

The CMC Transition of Care Process

A team of physicians and case management nurses will collaborate with physicians, treatment facilities and family members regarding treatment plans and ongoing care coordination needs for the patient. This includes ongoing monitoring for exacerbations and new conditions, as well as recommendations to primary care and home care physicians on medically necessary interventions.

In addition, physicians perform comprehensive reviews of the patient’s medical condition, including:

  • medical record
  • results of laboratory and radiologic investigations
  • medication history
  • hospitalizations and ER visits record
  • home care service needs
  • health maintenance record

Enrollment and Screening Criteria

This program is available to patients who are discharged :

  • from inpatient admissions with complex medical conditions
  • from inpatient admissions with complex post-discharge needs, or
  • home from inpatient admissions with catastrophic and acute medical events requiring complex home care services

Patients must also meet any of the following criteria:

  • have multiple diagnoses or a diagnosis that will likely result in repeated hospital admissions, or
  • have a history of repeated hospital admissions and/or the need for medically intensive services after discharge from a healthcare facility

Complex Case Management Program

Program Description

Program  designed specifically to coordinate and manage the care of medically complex patients recently discharged from hospital to ensure safe hospital discharges, continuity of management of chronic and catastrophic medical conditions in the community. The program also prevents frequent hospitalizations, or frequent Emergency Room visits. The case management program will coordinate and arrange ongoing medical care for the target population until their medical conditions are stabilized in the home setting.

Goals

Goals are to ensure safe hospital discharges, continuity of medical care in the home setting and stabilization of member with complex, chronic and/or catastrophic medical conditions.

Target Population

Patients with catastrophic and acute medical events resulting in high volume utilization  of medical services
Patients discharged from inpatient admissions with complex medical condition
Patients discharged from inpatient admissions with complex post-discharge needs

Enrollment/ Screening Criteria

Members are eligible to participate in the Medical Case Management Program if they meet all the following criteria:

  • Have multiple diagnoses or a diagnosis that has or will result in serious complications
  • Have a history of repeated hospital admissions and/or the need for medically intensive services after discharge from a  healthcare facility

Medical Review Process

Case management team work directly with hospitals, home health agencies, physicians and other providers to ensure the appropriate and expedited authorization of medically necessary services.

Case managers coordinate outpatient services to facilitate a patient’s hospital discharge to a home or community-based setting.  The program enables target population to avoid costly and repeated inpatient hospital stays and also ensures continuity of care.

Coordinate and facilitate the provision of medically necessary services available by means of expedited Treatment Authorization Requests.  Examples of services for which a case manager may seek authorization include home health services, Durable Medical Equipment (DME), medical supplies, non-emergency medical transportation, outpatient therapies and orthotics and prosthetics.

Assist in linking recipients with state, county and local programs.

Monitor recipients in the home setting to ensure continued well being.

Screen  recipients for enrollment in our disease management program

Length of Stay Management

 

Back to Top