Referrals
When referring a member into our Case Management program, CM staff must get a specific response from a member.
What is a member's consent to be enrolled into CM?
This assessment is only used for Medicare members.
What is the Health Risk Assessment (HRA)?
This comes up in TruCare automatically once an assessment is completed for a member if there’s not one already on file. Hint: the featured goals are not SMART.
What is a Care Plan Builder?
Member passes away, member relocates to another state or member requests to no longer be enrolled in Case Management.
What are reasons for a case closure?
This program provides specialized medical care for members with serious conditions and focuses on relief from ( symptoms, pain and stress) their diagnoses.
What is the Palliative Care Program?
Sunshine Health Case Management department refers members to this resource to provide members with local community resources within their zip code.
What is Aunt Bertha? (200 pts)
This assessment should be used when a member is discharged from an inpatient facility such as a hospital or rehab, etc. Hint: CM staff have 7-10 days from the patient's discharge to complete this assessment, however the goal is to get this completed within the first 72 hours of discharge.
What is the post TOC-Transition of Care Assessment?
This specific document is considered within the Care Plan and must be entered at creation and when following up with a member to review the member’s care plan.
What is a Care Plan Note?
Cases that involve a Tier1 Complex Case management member are also known as …...Hint: These members are the highest high-utilizers, they are in/out of the ER, also have both physical and behavioral health conditions.
What is a NCQA member or Tier 1 member case?
This program is exclusively for our members who are pregnant and provides ongoing support during and post pregnancy.
What is the SSFB-Start Smart For Baby program? 200 pts
Sunshine Health Case Management department refers members to this program to help members to stop smoking.
What is Tobacco Free Florida?
Each time a CM team member contacts a member this assessment should be completed if one is not already on file. This assessment assess the member’s current condition to see if they qualify for CM.
What is the HRS-Health Risk Screening?
This is a necessary element to show that care plans are focused around the member.
What is person or member centered “care plan”?
Cases that focus on a member's physical health and behavioral health conditions.
What is Integrated Case Management?
This comprehensive program identifies all members with this disease and provides them with basic information on the available benefits, educational materials, and offers a case management program to promote receipt of quality care and wellness.
What is the Sickle Cell Program?
The CM department refers members to this innovative program to help members with medication reminders, appointment reminders, transition of care resources and is even available for member's caregivers to use per member's consent.
What is Wellframe digital coaching?
As an incentive for completing certain assessments, the members will get financial rewards through the insurance company loaded into what type of card.
What is My Health Pays?
Care plans must include Problems, Interventions, Barriers and specific type of Goals.
What is SMART-Specific, Measurable, Attainable, Realistic and Timely?
Member is on a report and is offered Case Management services and agrees to be enrolled thus specifies the contact frequency that they wish to be contacted.
What is a creation of a case or enrolling a member into the Case Management program?
The goal of this program is to educate members about the appropriate use of ER visits, inform them on the differences between emergent and non-emergent care. Ultimately, better prevention will lead to less emergency room visits and inpatient stays thus reduce costs for the company also.
What is the EDD-Emergency Department Diversion program?
This digital coaching is exclusively for Ambetter members that have chronic conditions and could benefit from lifestyle changes.
What is Vida?
This assessment is to be used to satisfy NCQA requirements of documentation for community services referrals and follow up after initial referral.
What is the FL Referral Assessment (most recent version)?
This is a necessary care plan element that permits a care plan to be considered "active" in TruCare.
What is a taskable intervention?
Cases are reviewed and managed by various CM team members such as program coordinators, program specialists, and CHSRs but what CM staff member is the one who creates and maintains the member's care plan?
What is a Care manager?
This program provides support to members who are considered to be "medically fragile."
What is Enhanced Care Coordination program?