Case Management Programs
The purpose of the Case Management (CM) Programs at CCHP is to ensure that medically necessary care is delivered to our members in the most efficient and effective setting and for psychosocial barriers to receiving care are addressed quickly to minimize their negative impact. Case Management programs include:
- Comprehensive Case Management Program
- Health Risk Assessments and Care Coordination for our new SPD enrollees
- Comprehensive Perinatal Services Program for pregnant members receiving OB care with a community provider
- Good Health Check-Up Program
- Hospital Transitions Initiatives
Comprehensive Case Management Program
Complex case management is the coordination of care and services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. Since complex case management is considered an opt-out program, all eligible members have the right to participate or decline participation.
The goal of complex case management is to help members regain optimum health or improved functional capability in the right setting and in a cost-effective manner. It involves comprehensive assessment of the member's condition; determination of available benefits and resources; and development and implementation of a case management plan with performance goals, monitoring and follow-up. The primary goals of the program are to:
- Enhance the quality of life of the client
- Provide support and advocacy to member and provider
- Decrease fragmentation of care
- Promote cost-effectiveness
- Improve client and provider satisfaction
- Meet regulatory and accreditation requirements
Case Managers coordinate individual services for members whose needs include ongoing assistance with coordinating health care services. The Case Managers work collaboratively with all members of the healthcare team, including the Primary Care Provider, Specialist Providers, and Discharge Planners at the affiliated hospitals and Utilization Management staff at the Health Plan. In order to make a referral to the program, simply complete the referral form/fillable provided (Refer to Appendix C) and fax it to the CM Program. Telephone referrals can also be made. Leave a message including times you may be reached and someone will return your call promptly.
Comprehensive Perinatal Services Program
CCHP's Comprehensive Perinatal Services Program (CPSP) is available to all pregnant members receiving perinatal services by a community provider. CCHP believes that every baby should have a healthy start in life. We have a great opportunity to provide complimentary services, in conjunction with your exemplary medical care, to meet this goal. CCHP has a dedicated, full-time Medical Social Worker available for the sole purpose of providing CPSP services in the client's home or physician office. Services include basic nutritional services including assessment, education, intervention and referrals, a health education needs assessment, information and linkage to community educational resources, psychosocial support including crisis intervention, community resources, transportation needs, or any psychosocial problem affecting her care, and creation of an individualized care plan with active participation from the client. In order to facilitate early entry into this program, we are requesting that your office fax to us the first prenatal visit records within one week of the visit. We will make every effort to complete the Combined Initial Assessment and have the assessment and individualized care plan to you before the patient's next prenatal visit.
Fax First Prenatal Visit Records to:
Baby Watch Program
The Baby Watch program is part of CCHP Perinatal Case Management program. The goal of the Baby Watch incentive program is to promote good prenatal care with the goal of reducing the incidence of low birth weight babies and infant morbidity.
Certain pregnant CCHP members are eligible for the incentive program. In order to receive an incentive, eligible members need to do the following:
- Receive their first prenatal visit in the first trimester of pregnancy
- Return for a post-partum follow up visit within six (6) weeks of delivery
For more information about Baby Watch or to refer a CCHP member, please call:
Baby Watch Program
Good Health Check-Up Program
The Good Health Check-Up program is a CCHP quality initiative in partnership with Contra Costa Regional Health Centers and selected community providers, designed to improve Initial Health Assessment (IHA) compliance and HEDIS rates. The goal of the program is to increase the number of wellness appointments for selected CCHP Medi-Cal members through age eleven (11) while preserving, to the extent possible, continuity relationships with PCPs.
Seniors and Persons with Disabilities (SPD) Health-Risk Assessments and Care Coordination
CCHP's Case Management department conducts health risk assessments (HRA) on all newly enrolled SPD members. The results of the HRA, along with previous utilization data from the State, will be used to ensure quality transitional and ongoing care. The HRA will identify and address barriers to care access such as developmental, physical or mental health disability, transportation concerns, housing, food, medication management and caregiver support. Completed HRA's, and care plans for high-risk clients, will be sent to the primary care provider for consideration during medical management of the patient. Any questions about the HRA may be addressed to the team by contacting the Case Management unit at 925-313-6887.
Hospitals Transitions Initiatives
The Coleman Model, developed at the University of Colorado, Denver, is the framework for the Care Transitions Improvement (CTI) program at CCHP. The program is designed to improve the continuity of care as clients transfer from one facility to another (i.e. from the hospital to home) and reduce the risk of readmissions. During a 4-week program, clients admitted to Contra Costa Regional Medical Center (CCRMC) with complex care needs and their family caregivers receive specific tools and work with a Transition Coach to learn self-management skills that will ensure their needs are met during the transition from hospital to home.
Contra Costa Health Plan (CCHP) Hospital Transition Coordination Program facilitates the transition of CCHP clients admitted to a community hospital back to their assigned PCP and specialty care within the CCRMC network. The program consists of a designated phone line at CCHP which is answered by a specially trained RN. Services include identifying a member's assigned PCP and coordinating the transition of discharged patients back into primary care. Additionally, the RN will assist in coordinating specialty appointments, facilitating getting medical records to the appropriate provider to maximize appointment productivity, connecting patients to outside resources, and providing linkages to financial counselors for health coverage. Through this program we will not only enhance continuity of care between our health systems, but also reduce unnecessary ER visits and hospital readmissions. Our Hospital Transitions Coordination Program RN is available from 8am-5pm Monday-Friday.
Hospitals Transition Nurse