Peach State Provider Office Manual - Peach State Health Plan ...

data, hospital discharge data, pharmacy data, or data collected at any time through the UMprocess. Members may also be referred directly to the case management program through selfor family, DM program, hospital discharge planner, Provider, hospital case management staff,Peach State’s CONNECTION staff, Peach State utilization management staff or other PeachStaff. These multiple referral avenues can help to minimize the time between need and initiationof care management services.The Provider maintains an ongoing responsibility identifying members who may meet PeachState’s case management criteria.Health Risk Assessment and Case Management Plan:Once identified, the CM team uses various assessment tools to determine whether coordinationof services will result in more appropriate and cost effective care through treatment Peach Stateintervention. During this assessment of the member’s risk factors, patient information includingcultural and linguistic needs, current health status, potential barriers to complying with the caretreatment plan, and other pertinent information may be obtained from the member, family supportsystem, Provider and other healthcare practitioners. Assessment, care treatment, care treatmentplan and all interaction with the member is documented in CCMS (Care Enhanced CareManagement System) which facilitates automatic documentation of the individual and the dateand time when the CM team acted on the care or interacted with the member. CCMS supportsevidence-based clinical guidelines to conduct assessment and management and allows the CMto generate reminder prompts for follow-up according to the care management care plan.The Case Manager develops a proposed care treatment plan in conjunction with the member, theProvider, and authorized family members or guardians when possible. This proposed casemanagement plan is based on medical necessity, appropriateness of the discharge plan,patient/family/support systems to assist the patient in the home setting, communityresources/services available, and patient compliance with the prescribed care treatment plan..This care treatment plan includes short and long term goals, identifies barriers to meeting goals,provides schedules for follow-up and communication with members, and includes selfmanagementplanning and an assessment of progress against the plans and goals, withmodification as needed.The case management plan is implemented when the member, provider, case manager and /orother health care team agree to the plan. Checkpoints are put into place to evaluate and monitorthe effectiveness of care coordination/case management services and the quality of caseprovided, and to trigger timely revisions to the care treatment plan when necessary. Behavioralhealth care coordination is incorporated in the treatment plan. The case manager also assists themember in transitioning to other care when benefits end.Referring a Member to Peach State Case Management:Providers are asked to contact a Peach State Case Manager to refer a member identified in needof case management intervention:Case Management @ 1-800-504-8573OrTTY users @ 1-800-659-7487Special Needs Case Management ProgramsIn addition to general complex case management services, Peach State also provides specialneeds case management programs as follows:• Asthma• DiabetesProvider Services1-866-874-063302/22/201139