Member identification using a prospective approach that is designed to focus case management resources for       members expected to be at the highest risk for poor health outcomes

Initial and ongoing assessment

Problem-based, comprehensive care planning to include measurable goals and interventions tailored to the        complexity level of the member as determined by initial and ongoing assessments

Coordination of care with PCPs and specialty providers

Member education

Community Resources

Member empowerment using motivational interviewing techniques

Facilitation of effective member and provider communications

Program monitoring and evaluation using quantitative and qualitative analysis of data

Satisfaction and quality of life measurement

Using a prospective systematic approach, members with a risk of poor health outcomes are identified and targeted for case management services. This continuous case finding system evaluates members of a given population based on disease factors and claims history with the goal of improving quality of life through proper utilization of necessary services, community resources, benefits and a reduction in the use of unnecessary services.

Case management member candidate lists are updated monthly and prioritized to identify members with the highest expected needs for service. Case management resources are focused on meeting listed members’ needs by using a mix of standardized and individualized approaches.

A core feature of Case Management is the emphasis on an integrated approach to meeting the needs of members. The program considers the whole person, including the full range of each member’s physical, behavioral, cognitive, functional and social needs. The purpose of the program is to engage members of identified risk populations and to follow them across health care settings, to collaborate with other health care team members to determine goals and to provide access to resources and monitor utilization of resources. IntegraNet works with the member to identify specific needs and interfaces with the member’s providers with the goal of facilitating access to quality, necessary, cost-effective care.

Using information gathered through the assessment process, including a review of the relevant evidencebased clinical guidelines, IntegraNet develops a goal-based care plan that includes identified interventions for each diagnosis, short- and long-term goals, interventions designed to assist the member in achieving these goals and identification of barriers to meeting goals or complying with the care plan.

Assessment information, including feedback from members, family/caregivers and in some cases providers, provides the basis for identification of problems. Areas identified during the assessment that may warrant intervention include but are not limited to:

Conditions that compromise member safety

History of high service utilization

Use of inappropriate services

Current treatment plan has been ineffective

Permanent or temporary loss of function

High-cost illnesses or injuries

Comorbid conditions

Medical/psychological/functional complications

Health education deficits

Poor or inconsistent treatment/medication adherence

Inadequate social support

Lack of financial resources to meet health or other basic needs

Identification of barriers or potential barriers to meeting goals or complying with the care plan

Preparation of the care plan includes an evaluation of the member’s optimal care path, as well as the member’s wishes, values and degree of motivation to take responsibility for meeting each of the care plan goals. Wherever possible, the case manager encourages the member to suggest his or her own goals and interventions, as this may increase their investment in their successful completion.

We work closely with the member and providers to develop and implement the plan of care.

If you have identified a patient as a possible candidate for case management and wish to have them evaluated to see if they qualify, you can call 877-356-3705 or ask for someone in the Case Management department. The Case Management department is available Monday-Friday from 8 a.m. to 5 p.m. CST.