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Case Management Program VHP’s case management (CM) program is designed to help providers manage their VHP members and to assist members in obtaining needed services from community resources. These resources include covered and non-covered services when determined to be medically appropriate for the needs of the member. VHP’s CM team manages care for members whose needs are functional and social as well as those with complex medical and/or behavioral conditions. For pregnant members, pre-natal care, perinatal mood disorders and maternal mental health are areas where CM can assist members in receiving the appropriate, supportive care and services. Children with special health care needs may be at higher risk and are also appropriate for VHP’s CM program. VHP uses a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and health education. Case managers partner with providers to help the member achieve their selfmanagement health care goals. All VHP members are eligible for comprehensive CM programs, including complex CM, condition-specific CM, and autism spectrum disorder (ASD) CM. Members who have been identified with chronic complex, acute complex, high-risk conditions, or gaps in care, regardless of condition, generally benefit from intensive one-on-one advocacy care, care coordination, and education provided through CM programs.
Health Risk Assessment Screening VHP offers health risk assessment (HRA) screening to all Commercial Employer Group, CoCA and IFP members. HRA screening is voluntary, free of charge, and confidential. Information gathered includes current and past medical conditions, psychosocial network and support systems, barriers to health care, gaps in care, and self-care ability. The results are used in two ways: cumulative and individual. At the cumulative level, the information is used by VHP for program development. At the individual level, the information is used to identify members for case management programs and other quality initiatives
Case Management Team The CM team includes a Medical Director, Registered Nurses, Licensed Clinical Social Workers, Medical Social Workers, Care Coordinators and Community Outreach Specialists. The member’s designated case manager conducts a comprehensive assessment of the member’s medical, behavioral, and psychosocial needs through the administration of a health risk assessment (HRA) which supports the identification of barriers to care or well-being. The case manager is also responsible for the development and implementation of an individualized care plan as well as coordination of care among the member’s caregivers and providers to achieve good quality of care outcomes. Below Is a more detailed description of case management at VHP: Complex Case Management: • Case management for the highest risk or highest cost members; or • Members with multiple, ongoing physical, behavioral and social concerns.
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CH 18: Case Management
2021 / Provider Manual
