Case Management

Members who have certain chronic illnesses, require extensive follow-up or are following a complicated medical regimen are placed on a log for Case Management. These Members are followed by one of the nurse case managers to ensure and coordinate comprehensive care. Members who have been in the hospital for more than five days or Members who are readmitted to the hospital with the same diagnosis within 30 days may be added to the Case Management log. All case management Members are followed closely by the case manager and the Medical Director.

Case Management reviews all inpatient admissions to hospitals, skilled nursing facilities and other clinical settings for medical necessity and the appropriateness of care. During concurrent review, a nurse may: Obtain and document information for decisions of medical necessity. Determine the probable length of stay, based on appropriate guidelines for the Member’s diagnosis Evaluate, with facility staff, the Member’s discharge needs Coordinate the repatriation of Members to VMC. If an admission or continued stay does not appear to meet medical necessity guidelines, the VHP Medical Director will review the records. Medical necessity is evaluated utilizing nationally recognized standards. The UM Department may authorize transfers and referrals for post-discharge services, such as home health, DME or rehabilitative therapies.

When a Member is admitted to Santa Clara Valley Medical Center, an SCVMC case manager will coordinate post discharge services, such as home health care, durable medical equipment or skilled nursing.