Behavioral Health Case Management Programs

The Behavioral Health Case Management Program (BHCM) aims to improve the health and quality of life for members by helping them to identify and engage appropriate services to address behavioral health concerns. Members who participate will receive individualized assistance from a Behavioral Health Case Manager in arranging for the following services:

• Assistance with identifying appropriate services and resources in your area to help you address your concerns and improve your health and quality of life.
• Education regarding Behavioral Health issues, including both mental health and substance abuse
• Understanding how to better manage Behavioral Health issues, including family/caregiver roles
• Coordination of services with Primary Care Providers to manage health conditions which may contribute to Behavioral Health issues
• Referral to other Blue Advantage Care Management Programs that can assist you in managing other health concerns.

Complex Case Management Program

Blue Advantage’s Complex Case Management Program identifies members with complex healthcare needs based upon their chronic condition. The goal of Complex Case Management is to help members regain optimum health and/or improved functional capability, educate members regarding their chronic condition, teach members about self-management and preventive care, reinforce the Primary Care Physician’s (PCP) prescribed treatment plan, and provide information on resources that are available to our members.

The program is a telephonic case management program and involves a comprehensive assessment of the member’s condition, determination of available benefits and resources, development and implementation of a plan of care, and coordination of services. After a member has been identified for Complex Case Management, a Registered Nurse (RN) case manager will contact the member to perform an initial assessment and develop a plan of care. The case manager works closely with the member and the member’s physician(s) to coordinate care.

Enrollment criteria for Complex Case Management includes one or more of the following diagnoses:

• Congestive Heart Failure (CHF)
• Hypertension
• Atrial Fibrillation
• Coronary Artery Disease
• Diabetes
• Chronic Kidney Disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Asthma

Resources that we can assist you with if needed:

• Medication Therapy Management
• Blue Advantage Medication Adherence Program (PMAP)
• Tobacco Cessation Program by Certified Educators
• Diabetes Education
• Nutritional Services
• Behavioral Health Case Management

Referral identification sources include, but are not limited to:

• Provider Referrals
• Care and Disease Management Program Referrals
• Discharge Planning or Transitional Care
• Member Self-Referral
• Family Referrals
• Utilization Management Referrals

Referral Process:

Each referral is reviewed for enrollment in Complex Case Management based on available information and telephonic member assessment. Participation in this program is voluntary and at no cost for all eligible Blue Advantage members. If you would like to refer a member or if you would like additional information regarding eligibility into the Complex Case Management Program, please call toll-free 1-866-508-7145 (TTY 711).

Dual Eligible Special Needs Plan Case Management Program

The purpose of Blue Advantage’s Dual Eligible Special Needs Plan (DSNP) Case Management Program is to ensure that DSNP beneficiaries’ healthcare needs and preferences for health services are met over time. Case Management will help to maximize the use of effective, efficient, and high-quality care that will lead to improved health outcomes. The DSNP Case Management Program includes the delivery of services and benefits to members who are potentially medically complex, have multiple chronic conditions, and are disabled or facing psychosocial or socioeconomic difficulties. All Blue Advantage DSNP enrollees are enrolled in DSNP Case Management.

The DSNP Case Management Program includes a comprehensive initial assessment of each member's health condition, medical history and individual needs to identify available benefits, services and community resources. The program also supports the development, implementation and ongoing monitoring of an individualized care plan designed to address the member’s unique health and social needs. The individualized care plans include measurable goals, monitoring the member’s adherence to prescribed treatment plans and evaluates progress toward achieving their health goals. The program promotes early identification of health risks and opportunities for intervention among both new and existing members, ensuring that services are provided in a timely, effective, and member-centered manner. Through proactive care coordination, the program supports improved health outcomes, enhances the member experience, and facilitates collaboration with the member’s physicians and other healthcare providers.

The program helps members manage their health conditions and comorbidities by assessing and identifying clinical, behavioral, and social factors that may directly and indirectly affect their ability to access and receive appropriate care.  In close collaboration with the member, the member’s family or caregivers, healthcare providers, and the Interdisciplinary Care Team (ICT), Blue Advantage’s DSNP Case Management Program develops, supports, and reinforces an individualized care plan, tailored to the member’s unique needs. The program provides health education, promotes self-management skills, coordinates available healthcare and community-based services, and facilitates ongoing communication among all members of the care team to optimize health outcomes and improve quality of life.

Resources that we can assist you with if needed:

• Medication Therapy Management
• Blue Advantage Medication Adherence Program (PMAP)
• Diabetes Education
• Nutritional Services

Medication Therapy Management (MTM) Program

Palliative Care Program