1. health and fitness

Care Management Manual
6/26/14
SmartPlan Choice
Care Management Manual
Table of Contents
INTRODUCTION: CARE MANAGEMENT .............................................................................. 2
CARE MANAGEMENT OVERSIGHT ...................................................................................... 4
OVERALL CARE MANAGEMENT FLOW CHART ................................................................... 6
RISK STRATIFICATION ASSESSMENT ................................................................................ 10
Script for Provider Initial Discussion on Care Management .......................................................... 13
CONDUCT THE HEALTH RISK ASSESSMENT ...................................................................... 14
Basic Demographics .............................................................................................................................. 14
Medical & Surgical History.................................................................................................................. 14
Social History and Behavioral Functions............................................................................................ 16
Preventive Care ..................................................................................................................................... 16
CREATING A CARE PLAN .................................................................................................. 16
CARE MANAGEMENT FOLLOW-UP ................................................................................... 17
Tracking and Follow-Up with Patients in Care Management Case Load ................................... 18
Medium Risk Patients.......................................................................................................................... 18
High Risk Patients ................................................................................................................................ 18
Follow-Up Contacts ............................................................................................................................ 19
CARE TRANSITIONS .......................................................................................................... 35
CARE TRANSITIONS: FOLLOW-UP AFTER HOSPITALIZATION .......................................... 35
CARE TRANSITION: PCP TO MENTAL HEALTH PROVIDERS, SUBSTANCE ABUSE
PROVIDERS, SPECIALIST PROVIDERS AND VISA VERSA .................................................. 36
CARE TRANSITION: OUTPATIENT (PCPS, SPECIALIST PROVIDERS, MENTAL HEALTH
PROVIDERS, SUBSTANCE ABUSE PROVIDERS) TO INPATIENT ......................................... 36
CARE TRANSITIONS: INPATIENT TO LONG TERM CARE FACILITY OR HOME AND
COMMUNITY-BASED SERVICES ......................................................................................... 36
PCP AND CARE TEAM COMMUNICATION/HUDDLES ....................................................... 37
MAINTENANCE AND REMISSION...................................................................................... 39
Maintenance Visit .................................................................................................................................. 40
Care Manager Guide to Making a Maintenance/Relapse Prevention Plan ............................. 40
Maintenance/Relapse Prevention Plan ............................................................................................. 42
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Care Management Manual
INTRODUCTION: CARE MANAGEMENT
SmartPlan Choice addresses the variety of challenges faced by enrollees on achieving ideal healthcare.
Some members will have coverage for the first time and will benefit from orientation to concepts of primary
care, and access to primary care services in the appropriate setting. Many have gaps in care for
preventative services. Finally, many will have undiagnosed conditions, and those with chronic disease may not
be managed.
SmartPlan Choice will engage in initiatives to reinforce care plans and ensure that information is
communicated clearly with patients and their caregivers and coordinate care during transitions. A multidisciplinary/cross continuum of care team will coordinate roles, levels of acuity, specialties and facilities.
Better care coordination and care transition will result in better access to ambulatory and preventive services,
reduced in-patient utilization, reduced emergency department utilization and a reduction to all cause hospital
readmissions.
In addition, care coordination will be improved through increased communication through the local physician
hospital organizations (PHOs). In the PHOs, the network of care providers will be developed to meet the
unique needs of the target population. Community partners will be incorporated into the care coordination
efforts. For patients identified as medium or high risk, front line providers will have the opportunity to partner
with Care Coordinators to track and monitor the care of patients. The primary care physician will also be a
critical part of care coordination efforts.
In order to provide comprehensive, coordinated care for this growing population of Medicaid patients, the
work can be efficiently split into: a role of “care coordination,” a role created for deliberate organization of
patient care activities between two or more participants in a patient’s care to facilitate the appropriate
delivery of health care services; and a role of “care management,” a role designed for the engaging and
managing of the more complex medical, social, and behavioral health conditions of a caseload of patients.
Although care coordinators/managers can operate telephonically from centralized locations, randomized
control trials suggest that they are most effective when embedded within a primary care center/clinic as part
of the care team. They are trained to follow a standardized method for assessment, planning, and follow-up
that improves member compliance with the treatment regimen. The care coordinator can handle a larger
volume of coordinator activities with patients and work alongside of a care manager for more complex
activities, such as medication reconciliation and other treatment plan changes. The care manager is often the
primary point of contact for the more complex patients needing care management, facilitating communication
with the primary care physician and other care team members as needed. Both roles may participate in preclinic “huddles” to plan the flow of the day, making sure
that specific patient needs are addressed. By using a common medical record, care plan, and standards of
care, care team members communicate and collaborate.
Each member within a care team has specific roles, but they work together in an interdisciplinary manner to
provide seamless, high quality, holistic care for each patient.
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Care coordinator duties/skills include:
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Outreach to patients for on-boarding and risk stratification
Coordinate preventive services and chronic disease services needed
Coordinate information exchange where appropriate and routine communication linkages for
patients and the care team
Building trusting relationships with patients through follow-up phone calls and in-person contact
Empathizing, employing motivational interviewing, using change management techniques and
exhibiting cultural sensitivity
Care manager duties/skills include:
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Outreach to patients to engage them in care management services
Conducting screening and as indicated, comprehensive health risk assessments (HRA) as well as
other types of screening when needed
Creating care plans that follow clinical protocols, standing orders and work flows but also address
the felt needs of the individual complex patient
Building trusting relationships with patients through follow-up phone calls and in-person contact
Empathizing, employing motivational interviewing, using change management techniques and
exhibiting cultural sensitivity
Connecting with and involving other members of the care team as appropriate to achieve the best
care outcomes for patients
Assuring appropriate referrals are received
SmartPlan Choice
Care Management Manual
CARE MANAGEMENT OVERSIGHT
Responsibilities
The care managers for this population are specially trained in patient counseling, complex care coordination,
and population health management. Whether in person or through telephonic support, care coordinators will
interact closely with patients and families to improve patient satisfaction and adherence.
The care coordinator will become a partner for the physician and work directly with select patients who are
identified as high-risk. Under the direction of the patient’s primary care physician, the care coordinator will
develop, implement and continuously enhance an individualized treatment plan that will actively address the
patient’s ongoing medical needs and prevent an unexpected health crisis. The Care Coordinator will
encourage, facilitate and support patients’ self-management and work to increase their self-efficacy, and
help them become active participants in their own care.
Oversight of the Care Team
The medical director and front-line providers of the ACE will be meaningfully involved in the ACE governance
structure. The medical director’s role will be to oversee the development and implementation of the model of
care for the integrated delivery system. Specific duties of the medical director will include, but are not limited
to:
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Providing leadership in strategic planning for the ACE,
Providing input and medical leadership in annual goals and budget,
Overseeing care management,
Participating in provider relations/outcomes reporting,
Overseeing all aspects of medical care delivered by the ACE,
Reviewing new diagnostic and therapeutic innovations for inclusion in covered benefits,
Reviewing utilization management including signing off on any services denials,
Overseeing final credentialing decisions,
Developing and providing direct, and oversight of the clinical programs,
Serving as the primary liaison to network providers,
Serving as a liaison with legal counsel on legal issues, bylaws, and policies, and
Attending meetings of and presenting to the Board of Directors, the Quality Improvement Committee, the
Policy, Practice & Finance Committee, Consumer Advisory Board, and the Gynecological and Pediatric
Health Committee on all ACE activities.
The ACE will have a strong high-quality, high-value network of providers. Patient care will be provided
across the continuum through an extraordinary network of quality primary and specialty care physicians,
Presence Health hospitals and services, Presence Behavioral Health, other participating hospitals including
tertiary and academic providers, and post-acute care settings. Front-line providers will be an integral part of
the proposed ACE. Front-line providers will have the opportunity to participate in the local district councils.
The providers will also be empowered to provide direct patient education to program participants.
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TRAINING
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Cultural Competency. As part of the ACE, training will be given to providers on linguistic and culturally
appropriate care. In order to achieve meaningful access for limited-English proficient (LEP)
patients/families language assistance services will be provided. The ACE will have the opportunity to
utilize Presence Health’s Language Assistance Services policy which creates an environment of welcome for
limited English proficient patients while ensuring the provision of qualified medical interpreters to assist in
their conversation needs from the point of entry and all throughout their visit at any Presence Health
ministry. In addition, access will be provided to telephonic interpreter services as well as on-site qualified
medical interpreters for the interpretation of conversations between LEP patients and health care
providers seen at the Presence Health hospital locations.
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HIPAA/Privacy Standards. SmartPlan will provide training on HIPAA/Privacy Standards based on the
existing SmartPlan Choice policies.
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Care Management Manual
OVERALL CARE MANAGEMENT FLOW CHART
Care Coordinator Role:
Health Risk
Stratification
completed in OPTUM
tool
Member enrolls with
SmartPlan Choice
Is enrollee
managed by
PHP or
APEX?
APEX
PHP
Contact patient to make provider
appointment (if patient new or due
for f/u appointment) and conduct
initial risk stratification survey in
person or over the phone if patient
prefers.
Contact patient to make provider
appointment (if patient new or due
for f/u appointment) and conduct
initial risk stratification survey in
person or over the phone if patient
prefers.
Verify all patient
demographics in EHR.
Health Risk Questionnaire
Data entered into
Crimson
Continued next page
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Care Management Manual
Continued from previous page
Is enrollee
identified as high
or medium risk?
No
Patient continues on
care gaps list for
management of
preventive services
needs and other routine
tests and services.
7A
Yes
Patients identified as medium
or high risk are assigned to a
care manager for complete
HRA through Crimson and
ongoing care management
(per care manager guide).
Care managers receive
notification of patients at
medium or high risk level
and begin to make
contact.
Introduction to Care
Management with patient
approval.
Continued next page
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SmartPlan Choice
Care Manager Role:
Care Management Manual
Continued from previous page
7A
Patient
consents to
CCM program.
No
Patient continues with
usual care but will have
new contact to
reengage based on new
clinical trigger event.
Yes
Make appointment with
CM for longer visit and
conduct comprehensive
HRA.
Complete the comprehensive
HRA:Crimson
Using information from
comprehensive HRA, review with
PCP and begin development of
patient care plan.
Monthly care manager follow-up contracts with
patients that are at high risk (more frequent if
needed). Follow-ups have minimum of 3 areas:
 Review meds and side effects (other tx
High changes
Risk
 Review any new labs/appts./ED/Hosp
 Review self-management goals,
progress and barriers
 Review and discuss any routine labs,
tests, services needed to regularly
monitor progress for each chronic
medical condition
Every 2-3 months follow-up contacts with care
manager for patients that are at medium risk.
Follow-ups have minimum of 3 areas:
 Review meds and side effects (other tx
changes
Medium
 Review any new labs/appts./ED/Hosp
 Review self-management
goals,progress, and barriers
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Review and discuss any routine labs,
tests, services needed to regularly
monitor progress for each chronic
medical condition
Continued next page
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Continued from previous page
Meet with PCP (and other care team members as needed)
and get input and PCP sign-off on care plan.
Triggers to meet with care team:
 Review new CM patients
 Review CM patients not making improvements or
recently hospitalized/ED
 Review preliminary care plan and seek input from
other care team members
Patient
improving?
No
Yes
Patient at
management
goals?
No
Yes
Patient is at management goals.
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Initiate maintenance plan.
Discuss ongoing treatment.
Early warning signs of relapse and what to do
Less frequent contacts/visits with CM—decide if
care management services are still needed.
Discuss patient care plan
with PCP.
 May need PCP appt.
 May need appt. with
specialist.
 May need treatment
change.
 May need referral to
Community Behavioral
Health Partners
Continue ongoing contacts
with patient and routine
check-ins with PCP and
care team until patient is at
management goals.
SmartPlan Choice
Care Management Manual
RISK STRATIFICATION ASSESSMENT
SmartPlan Choice will utilize Optum health risk evaluation tool to complete the initial health risk stratification.
Medium and high risk enrollees will be directed to complete a health risk assessment. The health risk
assessment will be uniform for all enrollees with SmartPlan Choice. By completing a two-step risk assessment,
SmartPlan Choice has developed a process to complete a health risk assessment that takes into account both
medical and social histories for each enrollee.
The total risk score for medium and high risk enrollees will be calculated according to the following formula:
Risk Stratification (Score) = Optum Care Suite Initial Assessment (40%) + Health Risk Assessment in Crimson/
Software (60%)
Optum Care Suite Initial Assessment
If claims data are available when a member enrolls in SmartPlan Choice, it will be imported into the Optum
Care Suite tool. Optum Care Suite (OCS), specifically combines patient medical information from several
sources including Electronic Medical Record (EMR), practice management, Admission, Discharge, and Transfer
(ADT), and payer claims records into a single data stream. Then OCS applies analytics and decision-support
tools to help define and meet patient needs. This application calculates general risk scores to illustrate the
severity of risk associated with a particular patient for use of resources or costs of care over a period of time.
Higher scores indicate higher risk or higher costs. Risk scores are calculated once a month and each time new
patient data used in calculations are sent to the application. This information will assist in determining if the
patient has a medical need that is not met.
Inputs for the OCS risk score calculation include:
Future Cost Risk: Measures relative risk of health care expenditures
Admission Risk Score: Predicts the likelihood of a person being hospitalized
Inpatient Probability: Measures the likelihood that a patient will be admitted to an inpatient facility over the
next 3 or 12 months.
Inpatient Relative Risk: Compares a patient with a defined average to assess the likelihood that a patient will
be admitted to an inpatient facility over the next 3 or 12 months.
Readmission Probability (30 day): Measure represents the likelihood that a patient will be readmitted to ta
hospital within 30 days of being discharged. Data from claims and ADT messages identify the initial
hospitalization. The score evaluates additional data from EMRs and practice management systems for: days in
ICU setting, days in non-ICU setting, ER admission, concomitant conditions, use of health resources prior to
hospital admission, and demographics.
Readmission confidence level (30 day): Indicates how much data is available to support the readmission
probability score assigned to a patient.
Framingham 10-year Coronary Heart Disease: Estimates the probability of developing coronary heart disease
(defined as myocardial infarction or coronary death) within 10 years of being evaluated. This is calculated
each time new patient data is received by the application. The calculation uses electronic medical data
including numeric values for a patient’s total cholesterol, HDL and systolic blood pressure. It also takes into
account the patient’s age, gender, any treatment for hypertension and the patient’s current smoking status.
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OCS is fully customizable. PHP and APEX are updating the risk stratification algorithm with Optum to include
additional inputs including, but not limited to, compliance with preventative care services and screenings,
pharmacy utilization and medication management, risk for mental health episodes, risk for pediatric asthmarelated events, and probability of high risk pregnancy. High utilizers and high-risk pregnancies would be
reflected as high risk enrollees in this algorithm. The risk algorithm will continue to be reevaluated by the
Quality Improvement Committee as more information is known about this population.
Health Risk Questionnaire
If claims data is not available for a member, a SmartPlan Choice representative will call the enrollee within
the recommended number of days, per contract, to complete a Health Risk Questionnaire to obtain basic
medical information. Until more information is known about this population, the Health Risk Questionnaire will
be based on the health risk assessment criteria promoted by Blue Cross Blue Shield of Illinois. The health risk
assessment form will be revised, as needed, to meet the needs of the SmartPlan Choice population. Any
changes to the health risk assessment template will be reviewed and approved by the Quality Improvement
Committee.
A trained SmartPlan Choice clinician will manually assign a risk score of low, medium, or high based on MCG
guidelines and evidence-based standards. This score will be 40% of the total risk score for an enrollee. If a
member is deemed to be low risk after this initial assessment, the enrollee will be assigned to care
coordination by their primary care provider aimed at detecting gaps in preventive services or gaps in chronic
disease management. If deemed to be potentially medium or high risk after this preliminary analysis, they
will be asked by a PHP or APEX care manager to participate in a health risk assessment to further stratify risk
as low, medium, or high risk. Individuals that are identified as low risk will be monitored for gaps in care as
discussed above. For moderate or high individuals, the Optum score will be delivered to Crimson Care
Connect for enrollees under the care of Smart Plan Choice Crimson Software for those under the care of IPA,
where the other 60% of the score will be completed by using a health risk assessment. Medium and high risk
individuals will be asked to consent to care management prior to the completion of a health risk assessment.
Eventually, PCP’s will identify potentially suitable patients for care management as they come in for
appointments. The best approach to engaging a patient into care management in this situation is with a
“warm hand-off”: introducing the patient to the care manager at the time
the patient is in the clinic. The PCP making the introduction, being able to
Care managers receive
see the care manager as part of the PCP care team, and having the
notification of patients at
opportunity to discuss the program right away facilitate a good relationship
medium or high risk level
and begin to make contact.
between the patient and the care manager. It also increases the likelihood
of the patient scheduling and showing up for follow-up contacts/visits.
The care manager begins to contact the patients identified as medium or high risk to set up a time to meet
(preferably in person) to conduct the comprehensive HRA which will take 60-90 minutes.
Talk with patient about
CCM program.
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Reaching the Enrollee
Care Coordinators will attempt to reach a patient at least three times by phone. They will use contact
information provided by the state and work with the PCPs to verify and update information as necessary.
They will try to reach the enrollee on enrollment days 1, 3, and 10. The following script provides the care
coordinator with the appropriate language for each contact. If the care coordinator cannot reach the member
by the third phone call attempt, he or she will send the member a letter informing them that SmartPlan Choice
wishes to speak to them about their care plan (See Pre-enrollment Unable to Reach Letter). The care
coordinator will wait two weeks for the member to make contact. If the member has not made contact after
two weeks, he or she will attempt to call the member again. If the SmartPlan Choice representative cannot
reach the patient after this last attempt, the enrollee will be contacted again if a clinical trigger event occurs.
When setting up the initial call, the SmartPlan Choice representative will explain the care management
program and benefits to the patient. He or she will also ask the enrollees if this would be something in which
he/she agrees to participate.
Care Management Program Benefits:
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You understand your medical care
Answer questions and educate you about your treatment and/or care options
Make sure you know where you can find the treatments you need
Assist you and your family in finding resources to meet your needs
Keep your physician informed about your treatment and your needs
Script for Care Manager Initial Telephone Call
1. Introduce yourself:
Good morning/afternoon/evening Mr./Mrs/Ms. ______________. I am ______________, a care manager at
the ___________________clinic.
2. Explain how you obtained the patient’s name:
I work with Dr. ___________, who has asked me to call you and talk with you about our care management
program that he/she thinks could be of benefit to you with your current health care needs (could mention them
specifically – your diabetes, CAD, depression, your recent hospitalization, etc.)
3. Explain purpose of the call and nature of initial visit/contact:
I would like to schedule you to come in for a visit with me in the clinic. Or, would you prefer we meet by
telephone? During this visit/contact, I want to talk a little bit more with you about our care management
program and conduct a health risk assessment with you. This information should help you, me, and your provider
better understand your health care needs and what this care management program can focus on to help you get
better. The health risk assessment could take up to an hour or more to really go through and discuss with you.
4. Wait for feedback, if none, continue:
Do you have any questions at this time? If you have questions before we next connect, will you call me? (wait for
answer) Here is my direct number _________________. (have patient repeat it back)
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5. Schedule visit/contact:
When would be a good time for you to come to the clinic to meet with me or for me to call you?
6. Thank patient and provide contact telephone number and confirm their number and if allowed to
leave message at that number.
Thank you very much. I look forward to connecting with you on _______(date/time). If you have any questions
between now and our visit/contact, you will call me, won’t you? (wait for answer). My name again is
_____________and my number is________________.
Script for Provider Initial Discussion on Care Management
“I would like to tell you about how we care for patients with chronic diseases here at _____________. We use a
team approach, which means you (the patient), I (the primary care physician) and our care manager ________ are
a team. You may not know a lot about your condition(s) now, however, we will teach and work with you so you can
be actively involved in your care”.
“Your first visit with the care manager will give you a chance to meet and ask any question you may have about
what will happen/occur moving forward. _[CM name]____ will review and conduct with you at that visit a
comprehensive health risk assessment. He/She will also review that information with me and we can start creating
a care plan for all of us to work from and determine what will happen/occur moving forward. In other words, we
are a team and we are going to do everything we can to help you to feel better. You, I and the care manager
are a team, so it is important that we keep you involved in your care”.
“…………. The care manager works closely with me and we will coordinate all of your care. So, it is very
important that you feel safe in sharing with us, and more importantly your care manager. Do not hesitate to ask
any questions you have, share any problems or issues, and share good things that happen along the way.
Will you do that? …………. What would prevent or encourage you to do that?..................”
Patient consents
to CCM
program.
Yes
Make appointment with CM
for longer visit and conduct
comprehensive HRA.
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No
Patient continues with usual
care but will have new
contact to reengage based
on new clinical trigger
event.
SmartPlan Choice
Care Management Manual
If patient does not consent to the care management program, the Care Manager will advise the patient to set
up an appointment with his or her primary care provider. This patient may come back on the CM list another
time if:
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PCP talks with the patient, and the patient consents; or
Another clinical event triggers the need.
If patient agrees to participate in the care management program, set up a time/dates to meet with the
patient to complete the comprehensive HRA.
CONDUCT THE HEALTH RISK ASSESSMENT (HRA)
Complete the HRA.
Conduct the HRA with the patient, preferably in person; while this can be done by phone, some of the
questions and dialogue may not be as easy to communicate. Ask each question of the patient, and engage
him or her in further discussion in order to fully understand his or her response.
Enrollees will complete the assessment with their care manager through the Crimson Care Connect tool.
Both systems are built to complete a Health Risk Assessment containing the following sections:
Basic Demographics
The HRA will ask the patient for basic information. The care manager should consult the EMR for this
information prior to calling or meeting with the patient. Information that is already in the EMR will populate
into this assessment automatically. For the EMR sections, it is still highly recommended that the care manager
review the information for accuracy and confirm with the patient.
Demographic information to be asked or verify include, but is not limited to, the following:
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Member Number/ID
Name
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Address
Date of Birth

Gender
Medical & Surgical History
Some of the medical history of the patient will be in the EMR or the care manager may have access to the
information through other communications or encounter data, but it is still important to confirm the information
based on the knowledge and understanding of the patient at the time of the HRA interview.
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Questions asked by the care manager to collect a patient’s medical and surgical history include, but are not
limited to, the following:
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Vital Signs
History of Present Illness
Medications
Allergies
Other symptoms
Current or Former Diagnoses (Asthma, Cancer, Congestive Heart Failure, COPD, Bronchitis, Coronary
Artery Disease, Depression, Diabetes, Mental Illness, Substance Abuse, etc.)
Surgical History
Family History
History of Pregnancy (for females, only)
Immunization History
The questions pertaining to medications are very important for the care manager to consider in determining
how to work with the patient moving forward. It will be important to understand how the patient takes his/her
medications currently, his/her level of comprehension of how best to take his/her medications, and the reasons
for and challenges to not taking his/her medications or not taking them as prescribed.
If a patient is on several medications, and the care manager feels that there is any challenge or potential
challenge with adherence to these, they will work with the enrollee’s PCP to find a pharmacist to help the
patient with better or sustainable medication compliance.
Social History and Behavioral Functions
This section of the HRA covers functions, quality of life, activities of daily life and instrumental activities of
daily life. MCG Indicia for Care Management will be used as a framework for evaluation within the health
risk assessment. It inquires about the enrollee’s medical, psychosocial, functional, and cognitive needs, and
medical and behavioral health (including substance abuse) history.
Questions asked by the care manager to collect a patient’s daily function and social history include, but are
not limited to, the following:
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Language Preference
Communication Preference
Cultural Background
Education Level
Marital Status
Economic Condition
Housing Status and Number in Household
Children or Dependents
Occupation
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Nutrititon
Tobacco/Drug Use
Alcohol Use
Caffeine Intake
Sexual Activity
Exercise Habits
Method (s) of Transportation
Advance Directive Completion
Other relevant information
Any concerns arising from these questions should be brought to the attention of the PCP for consideration
regarding patient follow-up. The patient may need an appointment with the PCP, additional assessments,
referral to occupational therapy, social work, etc.
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Preventive Care
The last section of the HRA will focus on preventive care. A “gaps in care” list will be produced from Optum as
a trigger for any preventive service needing to be addressed today or set up for a future date. The care
manager can review this document and the entire HRA and give an overall assessment of level of care
needed and hand off sections of the follow-up work as appropriate. Special focus should be given to
determining gaps in immunization history and recommended screenings for the individual’s age and health
status.
The completion of health risk assessments will be tracked in the Smart Plan Choice Crimson Software. Both
systems include reporting capabilities allow monitoring of a compliance with the completion of health risk
assessments. SmartPlan Choice will complete the health risk assessment within the contracted time frame post
enrollment for enrollees stratified as high or moderate risk. A patient’s risk will be routinely monitored and reevaluated as needed.
CREATING A CARE PLAN
Individuals identified as medium or high risk will have an individualized care plan developed by a care
coordinator in consultation with their primary care physician, behavioral health, family, and/or other training
specialists. In addition, they will receive on-going support via education, re-assessments and consultation by
the care coordinator. SmartPlan choice will have a goal to complete care plans for medium and high risk
individuals within 45 days. However, this may not always be possible. Every attempt will be made to
complete enrollee care plans within (90) days after enrollment. The comprehensive HRA forms the basis for
the care manager to create a care plan with the patient. The care manager will also consult with the PCP, the
patient, and the state (if applicable) to incorporate any existing care plans into the development of new care
plans. The care manager will communicate HRA findings to the PCP, either electronically or face-to-face as
part of the process of creating the care plan. The care manager should continue to reference the information
obtained from the HRA during follow-up calls and visits with the patient; it may inform the discussions that may
be needed to ensure good care management for the patient (on self-management, goal-setting, additional
community or enabling services, referrals, etc.).
The individualized care plan will be tailored to the specific needs of each patient. Care Management
Program is an office-based method for delivering highly individualized primary care to chronically ill patients,
who would benefit significantly from a comprehensive program of clinical support. The types of patients that
will be managed include people who have multiple chronic illness such as: diabetes, hypertension,
hyperlipidemia, and depression or who have gaps or barriers in receiving care. Socio-economic needs
will also be used in the evaluation.
The care plan will be easily accessible, as it is the guide for care for the care manager, the PCP, and others
on the care team, including the patient. The health risk assessment scores and associated care plans will be
available in SmartPlan Choice physician portals (PHP and Apex). Initial Care Plans and revisions will also be
provided to the physician by the care manager through daily and monthly care management meetings.
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Care Management Manual
The care plan will:









Inquire about existing care plans and incorporate any details from the enrollee’s PCP into the
SmartPlan Choice Care Plan.
Incorporate an Enrollee’s medical, behavioral health, Long Term Service and Supports (LTSS), social,
and functional needs
Include identifiable short- and long-term treatment and service goals to address the Enrollee’s needs
and preferences and to facilitate monitoring of the Enrollee’s progress and evolving service needs.
Create crisis plans for an Enrollee with behavioral health conditions
Develop a wellness program plan
Include, in the development, implementation, and ongoing assessment of the Enrollee Care Plan, an
opportunity for Enrollee participation and an opportunity for input from the PCP, other Providers, a
legal representative, and the Enrollee’s family and caregiver if appropriate
Identify and evaluate risks associated with the Enrollee’s care including the potential for deterioration
of the Enrollee’s health status
Identify the Enrollee’s personal or cultural preferences
Develop action plans to address social, behavioral, or environmental barriers to executing the care
plan. This may be called a Service Plan and will be embedded in the Care Plan.
Medium and high risk patients have access to their individualized care plans with a hard copy and/or through
electronic access (patient portal). The patient portal also provided access to test results, summaries of care,
online appointment scheduling, and allows secure messaging with their care team. Secure text, email, and
interactive voice response may also be provided for reminders about appointments and refills.
Using information from comprehensive
HRA, review with PCP and begin
development of patient care plan.
Monthly care manager follow-up contracts with
patients that are at high risk (more frequent if
needed). Follow-ups have minimum of 3 areas:
 Review meds and side effects (other tx
changes
 Review any new labs/appts./ED/Hosp
 Review self-management goals and
progress

Review and discuss any routine labs, tests,
services needed to regularly monitor
progress for each chronic medical condition
CARE MANAGEMENT FOLLOW-UP
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Every 2-3 months follow-up contacts with care
manager for patients that are at medium risk.
Follow-ups have minimum of 3 areas:
 Review meds and side effects (other tx
changes
 Review any new labs/appts./ED/Hosp
 Review self-management goals and
progress

Review and discuss any routine labs, tests,
services needed to regularly monitor
progress for each chronic medical condition
SmartPlan Choice
Care Management Manual
The care coordinators for this population are specially trained in patient counseling, complex care
coordination, and population health management. Whether in person or through telephonic support, care
coordinators will interact closely with patients and families to improve patient satisfaction and compliance.
The care coordinator will become a partner for the physician and work directly with select patients who are
identified as high-risk. Under the direction of the patient’s primary care physician, the care coordinator will
develop, implement and continuously enhance an individualized treatment plan that will actively address the
patient’s ongoing medical and social needs to prevent an unexpected health crisis. The Care Coordinator will
encourage, facilitate and support patients’ self-management and work to increase their self-efficacy, and
help them become active participants in their own care.
Tracking and Follow-Up with Patients in Care Management Case Load
Crimson will keep an electronic record of the patients.
Care management continues with routine follow-up for each patient as guided below.
Medium Risk Patients
All patients who are identified as medium risk will be assigned a care coordinator who will develop an
individualized care plan for them in consultation with the patient and the patient’s physicians. The care
coordinator will monitor any changes that these patients may go through which would elevate their risk level
through regular communication with the enrollee and continuous monitoring through the Crimson Care Connect
tool. The care coordinator will also provide on-going problem solving interventions. Medication reconciliation
alerts and any in-network inpatient admissions would constitute a significant change in health status. The risk
score and associated care plan will be changed as necessary and documented through the Crimson Care
Connect. Patients identified as medium risk should be contacted minimally every 2-3 months. When initially
establishing relationships with patients and setting self-management care goals, more frequent contact with
patients is recommended (i.e. first 4-6 weeks). Medium-risk patients will be re-evaluated at least every six
months to determine if they can be downgraded to low risk.
High Risk Patients
All patients identified as high risk through the health risk stratification process will be assigned a care
coordinator who will develop an individualized care plan in consultation with the patient’s care team. This
multi-disciplinary team will be led by the care manager and will include other behavioral health specialists,
nurses, pharmacists, and social workers as clinically indicated. The team will ensure that the patients’ medical
and social needs are fulfilled, reduce barriers, ensure past ineffective interventions are addressed including
lack of social support to ensure they are receiving the proper care. Patients identified as high risk should be
contacted for follow-up at least every month. As with medium risk patients, more frequent contact may be
necessary initially, when establishing relationships with patients. High-risk patients will be re-evaluated at
least every six months to determine if they can be downgraded to a lower risk category.
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Follow-Up Contacts
At all follow-up contacts (regardless of risk level), the following items should be covered, at least:
1. Reviewing current medications, how the patient takes them, any side effects he/she may be having. If
there are any medication problems, advise/re-teach and do teach-back (See Complex Care
Management: Follow-Up Contact/Visit Worksheet for ideas.), or decide if this warrants an
appointment or check-in with the PCP.
2. Review any new test results and services or touches in the health care system since the patient was last
seen (e.g., radiology, blood tests, appointments with a specialist, ED or hospitalization). Update the
information in the EMR and on the care plan, and discuss with the patient and the PCP as needed.
3. Review and discuss any routine labs, tests, services needed to regularly monitor progress for each
chronic medical condition. Using standing orders as appropriate.
4. Review self-management goals, progress, and barriers. If this is the first follow-up visit since the initial
HRA completion, it may be necessary to set the self-management goals for the first time. Using
motivational interviewing skills/techniques, guide the patient on what manageable goals he or she
feels comfortable setting and timeframes for accomplishing.
Care Manager Case Loads
Care managers and care coordinators will share caseloads that include both medium and high risk
individuals. A high risk individual is weighted at four times the care responsibility of a medium risk
member. Smart Plan Choice Crimson Software care managers and their supervisors will monitor caseloads
to ensure appropriate coordination of care.
Medication Management and Prescription Monitoring
Software from InterMedHx will be used by care managers and PCPs to monitor prescription fill rates, noncompliance, possible drug interactions, and potential abuse or misuse. The medication management
process will be revised as needed to better serve the needs of this patient population when data is
received from the state.
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Highlights: CRIMSON
Care Management Manual
SYSTEM HOME SCREEN
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MEDICATION MANAGEMENT
APPOINTMENTS & DELIVERIES
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Care Management Manual
CARE NOTES
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CARE PLAN GOALS
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SmartPlan Choice
Care Management Manual
CLINICAL HISTORY
FORMS & ASSESSMENTS
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PATIENT PROFILE SAMPLE
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Care Management Manual
SYMPTOM MANAGEMENT
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TO DO LIST PROTOCOLS
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PATIENT CARE PLAN REPORT
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SAMPLE PATIENT REPORT
LAUGHTER, LISA
06/05/1945, Female
Current Location:
123 Dempster
C: 847.999.0077
Personal Residence
Des Plaines, IL 60016
risk level: High
Diagnoses, Procedures & Immunizations
Code
Description
Type
250.00
Diabetes
primary
401.1
Essential hypertension, benign
co-morbidity
486
Pneumonia
co-morbidity
518.3
Allergic pneumonia
history of
appendectomy
Procedure or
Immunization
Active Medications
Name
Strength
Directions
Metformin
500 mg
1 Tablet(s) 2x / day
Lisinopril
30 mg
2 Tablet(s) 2x / day
Allergies
Levaquin, aspirin, lactose
Previous Visits
St. Marys
ER Visit
May 21, 2014 - May 21, 2014
Reason for Visit
fell while intoxicated
In critical care during hospitalization?
Unknown
St. Marys
In-patient Admission
May 5, 2014 - May 6, 2014
Reason for Visit
headache
In critical care during hospitalization?
Unknown
Post-Discharge Support
Non-medical Home Care
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Date
12/3/2013
SmartPlan Choice
Care Management Manual
Upcoming Appointments & Deliveries
May 30, 2014
May 30, 2014
11:45 am
11:45 am
Ima Cardiologist
Dr. Cardiologist's office
Presence Resurrection Medical Center PRMC
Care Team Contact List
Care Manager (Primary)
Luis Gomez
Presence Health Partners Corporate
primary:312.999.9999
Providers
Cardiologist, Ima
Doggy, Snoop
Jedrzejek, Barbara
Physician
Physician
Care Manager (Secondary)
Presence Resurrection Medical Center PRMC
Presence Our Lady of the Resurrection POLR
POD 1
456 PHP Dr.
789 PHP Dr.
primary:773.234.6789
Chicago, IL 12345
Chicago, IL 12345
alt:224.213.6936
primary:312.630.8487
primary:312.630.8486
Other Individuals
Laughter, Larita
Laughter, Lois
Miles, Mandy
Other - Guardian
Legal Rep
Parent
primary:333.222.3333
primary:444.555.6666
primary:888.999.9999
Care Notes
Patient Historical Data on May 30, 2014 - 10:09 AM
Signed by Adrienne Hanrahan on May 30, 2014Hx of hypertension diagnosed in
2011, adult onset diabetes in 2000. Multiple admissions for hyperglycemia through ER 7X from 2012 - 2013 due to non-compliance of
meds. Admitted 11/13, for concussion and head laceration due to fall. Has a hx of non-adherence to her treatment plan. Recent onset of
headaches, extensive workup was negative per admit 5/5/14. Possibility of TIA. Will monitor closely for future incidents.
Progress Note on May 29, 2014 - 5:23 PM
Signed by Adrienne Hanrahan on May 29, 2014
Phone call to Dr. Doggy office: Patient had labs drawn on 5/13/14. Sodium was increased from 138 to 145 since blood work on 4/13/14
while inpatient. Pt placed on a salt restricted diet. Other Labs WNL. Results attached.
Outreach Note on May 22, 2014 - 11:25 AM
Signed by Adrienne Hanrahan on May 22, 2014
PCT Pt. Message left on answering machine.
Patient Historical Data on May 22, 2014 - 11:17 AM
Signed by Adrienne Hanrahan on May 22, 2014
MVP Template
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Progress Note on May 8, 2014 - 2:44 PM
Signed by Adrienne Hanrahan on May 8, 2014
Follow up with patient/family notes: Bidirectional communication.
Initial Assessment on Apr 30, 2014 - 11:23 AM
Signed by Adrienne Hanrahan on Apr 30, 2014
Here is our clinical hx, current health status, initial notes.
Care Plan Goals
PROGRESS LOGGED
1.
Diet / Nutrition – Patient and family will understand the specifics of a low salt diet and be able to teach-back to Care
Coordinator. (Signed by Adrienne Hanrahan on May 29, 2014)
Confidence: 8 Barriers: Daughter cooks all meals for family and the patient and she uses processed foods
2.
Wellness and Prevention – Pt will decrease intake of alcohol from 24 cans a beer to 6/day by 5 (Signed by Adrienne Hanrahan on
May 22, 2014)
Confidence: 1 Barriers: He lives with his wife who is an alcoholic and he is a bartender.
3.
Medication Management – Patient will take medications regularly through education and obtaining a pill box within 1 mos. (Signed
by Adrienne Hanrahan on May 09, 2014)
Confidence: 2 Barriers: does not have regular eating hours - forgetting to take meds regularly.
4.
Accessing Social and Community Services – Patient will contact Greater Chicago Food Depository @ 999-999-9999 within 1 week
to check on available services (Signed by Adrienne Hanrahan on May 07, 2014)
Confidence: 7 Barriers:
5.
Disease Process / Symptom Management – Patient will understand htn management and diabetes blood glucose control within 1
month (Signed by Adrienne Hanrahan on Apr 30, 2014)
Confidence: 5 Barriers: readiness to learn. Eats out a lot
Risk Assessment: risk level: High
risk score:
208
Profile and Psychosocial Data
value
weight
score
Reliable support available when needed
Sometimes
10%
20
fall risk
No Limitations
5%
5
access to reliable transportation
Always
5%
5
palliative care type
Palliative care not applicable
5%
5
imported risk score
Unknown
40%
0
Mental Illness / Substance Abuse Condition
3
10%
30
Level of Engagement
2
5%
10
Medications
value
weight
score
# of active meds
2
10%
20
BMI Assessment
value
weight
score
BMI Classification
4
5%
15
Tobacco Use Assessment
value
weight
score
tobacco use
3
5%
15
Risk Score Total
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208
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Care Management Manual
Psychosocial Data
Insurance
Medicare + Supplemental
Primary Language
English
Ethnicity
Latino
Ed Level Completed
No High School Diploma
Spouse / Partner Impact on Patient
No physical / emotional stress
Available Emotional Support
Moderate
Patient Self-Rated Health
Good
Stress Level
Low
Reliable support available when needed
Some times
Fall Risk
No Limitations
High Risk Med
No
Insurance
Primary -Medicare
Policy #:555-55-5555
Eff Start Date:
Group #:
End:
Member #:
Subscriber Name:
Contract #:
Pending To-Do’s
To Do
This patient is in the Complex Care Management
Program.- Perform initial assessment on the patient and
communicate any unusual findings to the physician.Review medication list, reconcile medications, and provide
education If necessary.- Identify all of the patients
providers and place the applicable providers on the care
team.- Review/monitor appointment schedule and enter
physician appointments if applicable. Document your
findings in a care note. NOTE: You must activate/schedule
the monthly recurring to dos on this patient to continue
calls on a monthly basis.
Assigned To
Luis Gomez
Due Date
May 3, 2014
Created By
Complex Care
Management Protocol
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Transition of Care Inpatient Follow Up #1: Call patient the
day after inpatient discharge and discuss/determine: Any
new meds? Review, reconcile and educate. Assess patient
understanding/ self-management status. PCP follow up in
72 hours (has the appointment been made); record the
appointment under Appointments and Deliveries.
Available support? Any barriers to success such as
transportation needs? Any ancillary services involved?
Evaluate patient understanding/ education of disease
process. DME evaluation/procurement. Identify any
barriers to success and determine goals for the patient.
Document your findings in a care note.
Care Management Manual
Luis Gomez
May 9, 2014
Transition of Care IP
Protocol
Luis Gomez
May 11, 2014
Transition of Care IP
Protocol
Barbara Jedrzejek
May 27, 2014
Adrienne Hanrahan
Luis Gomez
May 28, 2014
ED Visit Protocol
Luis Gomez
May 31, 2014
Transition of Care IP
Protocol
Luis Gomez
Jun 2, 2014
Complex Care
Management Protocol
This patient recently attended a physicians appointment.
Call the patient to:- Educate and reconcile new
medications, if applicable-Revise care plan goals and
problem list, discussing any barriers to success- Discuss
new treatment plan-Document your findings in a care note
Luis Gomez
Jun 5, 2014
MD appointment
Protocol
Transition of Care Inpatient Follow Up #3Call patient and
discuss the following: Health status Self-management
progress Verify compliance with treatment plan
Psychosocial support End the transition of care IP care
program and then place the patient into the appropriate
care program Document your findings in a care note.
Luis Gomez
Jun 30, 2014
Transition of Care IP
Protocol
This patient has been admitted to the hospital. Outreach
to the patient via phone call or in hospital visit to assess
care coordination needs. Document your findings in a care
note.
Contact Dr. Jones re: alcohol issues
ED Transition of Care follow up #2: -Call patient within 1
week post ED discharge to address any outstanding needs
or identify any barriers to success.-Document your findings
in a care note.
Transition of Care Inpatient Follow Up #2Call patient and
discuss the following: Health status Self-management
progress Verify compliance with treatment plan
Psychosocial support Document your findings in a care
note.
Complex Care monthly follow-up. Contact patient to
discuss:- Health status change- Self-management
progress- Verify compliance- Psychosocial support- Future
appointments- Intervention needs Document your findings
in a care note.
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Weekly Medications Checklist
Last updated on
Unscheduled Medications
Lisinopril (30 mg) – 2 Tablet(s) 2x / day ()
Metformin (500 mg) – 1 Tablet(s) 2x / day ()
Symptom
Management
Guide
If this happens...
Do this...
Contact
Increased Blood Pressure
Call non-emergency
Call non-emergency
(999-999-9999)
Glucose level above 250
Notify Snoop Doggy
Notify Snoop Doggy
(312.630.8486)
Increased redness or
tenderness (wound)
Contact Dr. Smith's
Office
Weight Gain of 5 pounds
or more
Notify Ima Cardiologist
Notify Ima Cardiologist
(312.630.8487)
Decreased ability for selfcare
Notify Snoop Doggy
Notify Snoop Doggy
(312.630.8486)
Emergency
Note
Action
Required
Contact
Medical
Provider
Self Care
Fever
Required
Take Tylenol prn
Take Tylenol 500mg.
Call Dr. Doggy if fever
does not go down, or if
fever is over 100.1
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Care Transitions
SmartPlan Choice will facilitate the delivery of the right health care services in the right order, at the right
time, and in the right setting. SmartPlan Choice is committed to achieving this goal by aligning the
appropriate delivery of health care across the care continuum. This starts by assisting each member to choose
a PCP and then reinforcing the centrality of that PCP relationship. When specific cultural and linguistic needs
exist, the member will be offered a PCP that is best suited within geographic accessibility to meet those
needs. Emergency room utilization rates will be monitored as a proxy to access to PCP care. This data will
indicate if beneficiaries are accessing services more suited for a physician office visit. Outliers will be offered
care coordination services to assist in changing care to the PCP setting when clinically appropriate. When a
member is referred to other care settings for services that cannot be provided by the PCP, it is important that
these transitions are appropriately managed with good communication among the involved providers.
CARE TRANSITIONS: FOLLOW-UP AFTER HOSPITALIZATION




Proactive discharge planning will be prepared before and while in the acute care setting. In addition,
an understandable discharge plan will be clearly explained to beneficiaries, families and caregivers
Care transitions will be managed according to the Coleman Care Transitions Program within the
Crimson Care Management tool. The care manager is alerted when a patient has been hospitalized
and later when discharged. The inpatient care manager will secure an appointment with the PCP
within 7 days of discharge. If a care manager has been assigned to the patient, a corresponding
appointment slot is reserved on the PHP or APEX care manager’s schedule as well. The care manager
watches for the discharge summary and if necessary, proactively calls to secure it prior that patient
appointment. A designated out of network care manager will coordinate care for those enrollees that
are discharged from out of network inpatient facilities.
Care manager conducts the transition call or visit to a discharged patient within 72 hours postdischarge. The transition call includes:
o A discussion about medications including any new ones, how to take, any side effects and a
reconciliation with the previous medication list
o General health since discharge
o Recognition of condition specific red flags that could indicate condition deterioration and how
to communicate such warnings with the care team
o Family/friend support, do they need more care
o PCP appointment confirmation, do they have transportation
o Any other needs
Patient comes in for post-hospitalization visit with PCP and care manager reviews with patient:
o Discharge summary – why were they hospitalized
o Medication list – what is new, what is stopped, how are they taking them, any side effects
(decide if want a pharmacist on the team as well). Resolve any discrepancies with PCP
and/or pharmacist.
o Any other tests that were done that need results reviewed or still waiting on results and need
follow-up
o Ongoing home support the patient has or needs
o New self-management goals in order to prevent another hospitalization
o Use teach-back and motivational interviewing techniques for patient activation and goal
setting and any visual tools that will help the patient with adherence, i.e., med sheet with each
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pill they are taking on it and what it is for and how to take, appointment calendar showing all
future provider appointments, care manager call-backs, etc.
If there are already established self-management goals, assess progress towards those goals and reinforce
what is working and/or work with the patient to update the goals as needed.
If, upon reviewing the patient’s most recent results and adherence to the treatment plan, it would suggest a
modification to their care/treatment plan, this can be done.
CARE TRANSITION: PCP TO MENTAL HEALTH PROVIDERS, SUBSTANCE ABUSE
PROVIDERS, SPECIALIST PROVIDERS AND VICE VERSA
SmartPlan Choice has an extensive network of specialty care throughout the target geography including
obstetrics/gynecological and pediatric specialists. The network will work with enrollees to ensure that they
have adequate access to specialty care. We will monitor referral dates to billed encounters as a proxy to
determine adequate specialty care is available.
The individualized care plan will be utilized between primary care physicians and other specialists (after
patient consent is approved to share information about substance abuse, HIV, and other mental health
information), including but not limited to mental health providers, substance providers, specialists providers,
and vice versa. Enrollees that are identified as medium or high risk will be provided additional support
through the care coordinators, who will monitor their transitions between different specialists and identify
additional social and community supports when needed. Those individuals identified as low risk, interventions
will focus on prevention and early detection using phone call reminders and other patient engagement
practices.
CARE TRANSITION: OUTPATIENT (PCPS, SPECIALIST PROVIDERS, MENTAL
HEALTH PROVIDERS, SUBSTANCE ABUSE PROVIDERS) TO INPATIENT
Every member will be empanelled to a PCP and this information is available to emergency room physicians
and hospitalists. When a PHP assigned member is seen in a Presence owned ER or inpatient setting, they will
have access to that member’s outpatient record through Epic. All SmartPlan Choice PCPs are expected to
either be available or have arranged 24/7 coverage with a clinician who has access to their outpatient
electronic health record so that hospital-based providers can make care decisions that are informed by this
outpatient record. The individualized care plan will serve as a means of communication between the
outpatient and emergency room or inpatient settings for medium and high risk individuals.
CARE TRANSITIONS: INPATIENT TO LONG TERM CARE FACILITY OR HOME
AND COMMUNITY-BASED SERVICES
All members who are nursing facility level of care and discharged from the hospital to long term care services
and support (LTSS) in either an institutional or community-based setting will have a care manager assigned to
manage that transition of care. There will be direct communication between the discharging nurse and the
individual responsible for the individual’s LTSS. The assigned Care Manager will use the Eric Coleman
transition of care model to manage these discharges as described above.
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SMARTPLAN CHOICE COMMUNICATION/HUDDLES
Meet with PCP (and other care team members as needed) and get
input and PCP sign-off on care plan.
Triggers to meet with care team:
 Review new CM patients
 Review CM patients not making improvements or recently
hospitalized/ED
 Review care plan started and add from other care team
members
Discuss patient care plan with PCP.
 May need PCP appt.
 May need appt. with specialist.
 May need treatment change.
 May need referral to Community
Behavioral Health Partners
No
Patient
improving?
Yes
No
Patient reach
management
goals?
Continue ongoing contacts with patient and
routine check-ins with PCP and care team
until patient is at management goals.
Yes
Presence Health Partner facilitates a care team communication huddle. As a care manager gains experience
with his/her PCPs, he/she will establish processes with each for how best to keep the PCP informed and up-todate on his/her patients and when there is a potential change in care treatment needed.
Criteria to use for weekly communication/huddles with PCP/care team:
1. Any new cases/completion of the comprehensive HRA that week
2. Any severe cases—the patient’s condition is at a severity level of not-in-control, or the patient was just
hospitalized for his or her condition
3. Patients not responding to current treatment
4. Patient lost to follow-up (“no show” to appointments and cannot get on the phone)
5. Care manager feels the patient needs to be reviewed by the PCP
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COMMUNICATION FORM: PCP AND CARE MANAGER
Date: _______________________
Patient Name: ________________________________________ DOB: ______________
Primary Care Provider: ________________________________________
Care Manager: _______________________________________________
PCP preferred mode of communication:
email
telephone
pager
in person discussion
other: ___________
PCP preferred communication style:
Brief and few details with focus on specific problem or issue
Detailed discussion when time permits
Include (pharmacist, specialist, other): ___________________________________ in our communications
Other: _______________________________________________________________
Main reason for communication:
new patient to CM
not making improvement
CM concern
Length of time patient on current treatment plan: _______________________________________
Problematic side effects of medications: _______________________________________________
_______________________________________________________________________________________
Primary symptoms not substantially improved___________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Recommendations: ____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Maintenance and Remission
Patient is at management goals.




Initiate maintenance plan.
Discuss ongoing treatment.
Early warning signs of relapse and what to do
Less frequent contacts/visits with CM—decide if care
management services are still needed.
The goal in any type of care management model is to partner with the patient to help him/her become more
self-sufficient in understanding and managing his/her own health care needs, and therefore sustaining positive
changes. SmartPlan Choice recognizes that studies consistently show that patients are more likely to engage
and participate in their healthcare when they receive individualized care information. The first critical step in
developing individualized care is to gain a greater understanding of the unique situation of each beneficiary
(needs, preferences, values, barriers, and priorities). The second step is to align the unique needs of the
patient with specific engagement techniques that increase "facilitating behavior" and overall patient
empowerment from physicians, nurses, and other providers. Training opportunities will be provided on
methods for participating providers to improve this type of behavior and to engage patients through
techniques such as introducing him/herself when entering a room, introducing other staff, sitting down, and by
asking about the patient's needs. In addition, an identified individual health risk assessment will be provided
to the patient at their initial visit. This information will be utilized to identify patients at moderate or high-risk.
Patients that are identified as potentially high risk will be paired with a case coordinator for additional
support.
Patient engagement process will be a continuous process. Patients and their families will be involved as
partners in designing, developing and improving care within the ACE. SmartPlan Choice will promote patient
engagement through the planning, delivery, and evaluation of health care grounded in mutually beneficial
partnerships among health care providers, patients, and families. Areas for improvement will be identified
by the board through the quarterly review of the target measures (cost and quality). In addition, regular
town halls to explore feedback from consumers and stakeholders will be explored. SmartPlan Choice will
work with existing community partners and consumer advocacy organizations to co-host these town hall
meetings. As areas for improvement are identified, the board will develop design teams to implement new
care processes to improve quality, efficiency, and patient experience. Some examples of patient involvement
include flexible policies allowing open visitation, online access to medical records, and significant investments
in the physical environment to promote healing.
Patients can take 6-18 months to get to a point of good, controlled care management and feel
knowledgeable and confident about continuing to maintain that level of care management on their own.
During all of the routine follow-ups with a patient—monitoring lab results, patient readiness, medication
adherence, and overall management—the care manager will communicate with the PCP and the patient to
collectively decide whether this patient is ready to be “discharged” form the care management program. The
care manager will meet with the patient for a “maintenance” visit.
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Maintenance Visit
Meet with the patient to:



Review ongoing treatment plan, progress made, and rationale for continuing treatment. Reinforce
patient’s motivation.
Review risk factors.
Discuss early warning signs for relapse.
o Have the patient identify what his/her early warning signs may be.
o Create plan of action when those warning signs present: who to call; how soon; and how?
Review numbers for care manager and PCP.
o Next steps with PCP follow-up and care manager follow-up
The care manager maintains this patient in his or her case load list, but categorizes the patient as in
“maintenance phase.” The care manager will continue to call the patient every 3-6 months, eventually
lessening the number of calls to annually or when an appointment with the PCP is needed.
Care Manager Guide to Making a Maintenance/Relapse Prevention Plan
The goal of making a maintenance/relapse prevention plan is to prevent a relapse or recurrence of symptoms
as much as possible. A number of steps are involved in making a plan.
•
Review the course of the disease(s) and treatment up to now and address the following:
o Symptoms onset
o Impact of the disease on the patient’s ability to function at home and at work
o Current treatment(s) and treatment(s) tried before
o Questions about treatment(s)
•
Review risk factors for relapse/exacerbation of symptoms
These will be specific to each condition/disease and should be on the care plan and guided from the
PCP
•
Review the rationale for continuing medication and other treatment modalities prescribed on the
care plan and encourage the patient to do so
Besides staying on medications, there are a number of other things patients can do to prevent a
relapse of their condition, and you will spend the rest of the session working on this using behavioral
activation and motivational interviewing skills and techniques around other lifestyle modifications that
can help to keep them healthy and in good clinical management.
Get a sense of what might motivate the patient to stay on long-term medication and/or lifestyle
modifications and behaviors they need to sustain. Reinforce the patient’s motivation to do so as much
as possible.
Such as, if they have been hospitalized for this condition in the recent pass, ask the patient, how that
experience was, how did it affect their lives (financially, family, quality of life, overall healthy
feeling), would they want that to happen again, and then focus on helping them understand what they
can do and can control that will help to prevent them from going back into the hospital or the ED or
having that unpleasant episode they experienced before.
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Be careful not to sound like you are trying to control the patient’s behavior. Be empathetic. Try to
understand the patient’s perspective and concerns. You may want to point out that the primary care
provider and you want to help prevent a relapse, but it is up to the patient to continue in treatment.
“This is a decision you have to make yourself.” Let the patient know that you believe he or she can
take some action, which will significantly reduce their risk of relapse and give them more control over
their health.
If you sense resistance, carefully explore what may be difficult for the patient at this time. Having
them articulate the difficulties opens up for conversation around asking the patient, what could they
do differently to get around the specific difficulty. Help them brainstorm, but it really needs to be the
patient’s ideas and they need to agree to do something for themselves – not for you, or it will not be
sustained.
•
Discuss early warning signs of worsening condition(s)
Common early warning signs may be listed by the provider (may even be noted on the care plan)
and or per protocols for each disease specified. However, early warning signs may differ from
patient to patient and so helping the patient to identify for themselves how things feel or happen
differently when they are starting to not be as well controlled in their disease/condition.
Patients and significant others can learn to recognize such early warning signs and get help before
relapses/exacerbations become severe.
•
Make a maintenance/relapse prevention plan
It can be very discouraging to experience a recurrence of symptoms and not feel well controlled in
your disease state. If patients can detect these symptoms early on, however, it may be easier to
prevent a severe relapse.
Encourage patients to think seek help when these early warning signs occur. Seeking such help should
not be seen as a sign of failure, but as a positive step (i.e., “I am doing something to take care of
myself.”).
A relapse prevention plan for the patient includes early warning signs and a plan for what to do if
you or a significant other notices such symptoms. The plan can include:
o
o
o
o
Making sure you are taking the medication as prescribed
Reviewing care plan and other treatments recommended
Contacting the care manager
Contacting the primary care provider or making an appointment
•
Remind patients that both you and the primary care providers are available and how you can be
reached
•
Discuss future clinic or telephone follow-up contacts*
Tell the patient that you would like to schedule a telephone follow-up appointment periodically to
make sure that he / she continues to do well. During these contacts, you will review symptoms, any
new or needed test results, and review any current treatment.
Let the patient know that you will be in contact with his or her primary care provider to let them know
how the patient is doing.
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Maintenance/Relapse Prevention Plan
Patient Name:
Today’s Date:
Contact / Appointment Information
Primary Care Provider:
Tel. No.
Next appointment: Date:
Care Manager:
Time:
Tel. No.
Next appointment: Date:
Time:
Maintenance Medications
Review medication lists on care plan, how to take, length and frequency before refill and follow-ups
Other Treatments
Review other treatments to maintain, other specialist appointments, etc.
Goals: How to maintain goals achieved
1.
2.
3.
4.
Personal Warning Signs
1.
2.
3.
4.
5.
If symptoms return, contact:
Care Manager Signature:
Date:
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A RESOURCE FOR INVOLVING FAMILY AND FRIENDS
Scripts for Family and Friends
1. I see that (or can ask if patient has someone with them) you have a family member or friend with you
today. Would you like to have them join us? It can be helpful to have family or friends involved in
helping us set-up a plan of care and being a part of your care management that works for you.
2. Would you like anyone in your family or a friend to have information about your treatment? It can
be helpful to share information with another person, and also for us to receive information that may
affect your care.
We do need your written permission to allow communication with your family member/friend.
Would you be willing to sign a release form to allow this?
3. Having someone close to you who knows the signs and symptoms of your condition(s) and is queued in
or aware of how you are feeling on a daily basis, can help prevent a relapse/exacerbation. Is there
a family member or friend that you’d like to have involved in this part of your care planning?
Family and Friends refer to:
•
•
•
•
•
Spouse
Partner
Friends
Significant others
Caregiver
Social Support:
To assess for social support:
•
•
•
•
How many friends or relatives do you see or hear from at least once a month?
Which friends or relatives do you have the most contact with?
Do you talk to any of these people about private matters?
Do you ask any of them for advice on private matters?
Discuss early warning signs.
Patients and significant others can learn to recognize such early warning signs and get help before symptoms
become severe.
In many cases, spouses or significant others may notice such warning signs before a patient does, and it can
be very helpful to involve them in the monitoring for such signs.
Resources:
Add specific for patient conditions
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ACCESS TO SPECIALTY CARE INCLUDING BEHAVIORAL HEALTH
SmartPlan Choice will facilitate the delivery of the right health care services in the right order, at the right
time, and in the right setting. The ACE is committed to achieving this goal by aligning the appropriate
delivery of health care across the care continuum. SmartPlan Choice is confident that the participating
providers in the ACE are committed to care coordination efforts. The network already has experience
with integrating intensive ambulatory care coordination programs, health risk assessments, and patient
centered medical home for Medicaid, Medicare and commercial populations using linked medical data,
predictive modeling, consolidated call centers and medication management programs.

Promote access to all necessary care. Specific enrollee needs for access to care will be identified
through the comprehensive health risk assessment. As part of the assessment, the participant will be
evaluated for their specific cultural and linguistic needs, visual and hearing needs, the availability of
community resources, and specific caregiver supports. If a specific need is identified, a care
coordinator will work with the enrollee to ensure appropriate access to care. In addition, ED utilization
rates will be monitored as a proxy to access to care. This data will indicate if beneficiaries are
accessing services more suited for a physician office visit. In addition, patients will be monitored 7-day
follow-up post hospitalization to ensure appropriate provider access and availability.

Improve access to specialty care. SmartPlan Choice has an extensive network of specialty care
throughout the target geography. The network will work with enrollees to ensure that they have
adequate access to specialty care. In particular, SmartPlan Choice will work to ensure that there are
adequate obstetrics/gynecological and pediatric specialists within each of the target markets. We
will monitor referral dates to billed encounters as a proxy to determine adequate specialty care is
available.

Ensure that providers work together to coordinate care. SmartPlan Choice will facilitate care
coordination in each of the target markets. An educational campaign in each of the target markets
within the first year about requirements and care coordination expectations. Ongoing support will be
provided through the HIT support infrastructure. In addition, care managers will provide ongoing
support for enrollees identified as medium or high risk.
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HEALTH PROMOTION
Providers will provide input into patient education efforts to meet the unique needs of the target population.
Illinois based EMMI solutions is a content provider to PHP for patient activation and patient engagement
efforts that include interactive voice response technology (IVR) to support patient outreach for preventive
services and chronic disease management.

Patient Engagement Program. SmartPlan Choice recognizes that studies consistently show that patients
are more likely to engage and participate in their healthcare when they receive individualized care
information. The first critical step in developing individualized care is to gain a greater understanding of
the unique situation of each beneficiary (needs, preferences, values, and priorities). The second step is to
align the unique needs of the patient with specific engagement techniques that increase "facilitating
behavior" and overall patient empowerment from physicians, nurses, and other providers. Training
opportunities will be provided on methods for participating providers to improve this type of behavior
and to engage patients through techniques such as introducing him/herself when entering a room,
introducing other staff, sitting down, and by asking about the patient's needs. This curriculum will be
developed after SmartPlan Choice has a better understanding of the needs of this population. This will
allow SmartPlan Choice to make the best use of its limited training resources and target specific patient
engagement issues. In addition, an identified individual health risk assessment will be provided to the
patient at their initial visit. This information will be utilized to identify patients at moderate or high-risk.
Patients that are identified as potentially high risk will be paired with a case coordinator for additional
support.
Patient engagement process will be a continuous process. Patients and their families will be involved as
partners in designing, developing and improving care within the ACE. SmartPlan Choice will promote
patient engagement through the planning, delivery, and evaluation of health care grounded in mutually
beneficial partnerships among health care providers, patients, and families. Areas for improvement will
be identified by the board through the quarterly review of the target measures (cost and quality). In
addition, regular town halls to explore feedback from consumers and stakeholders will be explored as
trends in this population begin to develop. SmartPlan Choice will work with existing community partners
and consumer advocacy organizations to co-host these town hall meetings. Some examples of patient
involvement include flexible policies allowing open visitation, online access to medical records, and
significant investments in the physical environment to promote healing.

Consumer Advisory Board. SmartPlan Choice will have a consumer advisory board that meets regularly
and advises on policies and programs. The Board will develop cultural competency initiatives, outreach
plans, and enrollee education materials. It will establish patient advisory committees and/or focus groups
at the hospital participant sites as needed to engage beneficiaries in their care and obtain direct
feedback that can be utilized in our quality and process improvement initiatives. Enrollee satisfaction
surveys, quality improvement programs, educational and prevention programs will also be developed by
the group.

Electronic Patient Engagement. Patients will be engaged through electronic patient tools such as
interactive voice responses calls and the use of mobile applications. In addition, secure texting that is
HIPAA compliant will also be explored. SmartPlan Choice will also utilize a website, email distribution lists,
etc. to solicit input from members, family members, caregivers, and consumer advocates.
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COMMUNICATION
a. Care Coordination Program FAQs
Informs members of the role of a care coordinator in their care plan
b. SmartPlan Choice Welcome Letter
Welcomes the member to SmartPlan Choice and informs the member about the services provided
under their SmartPlan Choice membership.
c. PCP Notification Letter
The care coordinator will use this letter to inform a member’s PCP about his or her enrollment in the
care coordination program. The letter outlines the need for care coordination and includes a call to
action for the physician to become engaged in and approve the care coordinator’s care plan for the
member.
d. Pre-Enrollment Unable to Reach Letter
This letter will be used by a care coordinator when the member is not reached by phone after three
attempts.
e. Example Script for Care Coordination Enrollment (Diabetes)
Example script, based on MCG guidelines, is available for a care coordinator to use when contacting
a high risk member with diabetes. MCG provides care coordinators at SmartPlan Choice with ample
information and tools to care for the most complex patients.
f. Enrollment Confirmation Letter
This letter outlines the PCPs assigned to a member when they enroll in SmartPlan Choice. It also
provides information on how to contact SmartPlan Choice.
g. Patient Outreach Letters
Letters and interactive phone calls will be used to send reminders to patients about setting up
appointments with their PCP and about various screenings that are recommended for their age
groups. Additional letters will be created by the care management team as SmartPlan Choice learns
more about its patient population.
h. Provider Outreach Letters
Communication to PCPs is essential. These letters will be sent to providers to remind them about
promoting preventative screenings among their patient populations. These messages will be reinforced
through phone calls, meetings with care coordinators, and during meetings with PHP and APEX
leadership.
i.
Emmi Automated Voice Calls – Example Scripts
Scripts for interactive voice calls to patients will serve the same purpose as the patient outreach
letters. Additional letters will be created by the care management team as SmartPlan Choice learns
more about its patient population.
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