Medical Management

Medical Management Programs

Community Case Management

Community Case Management is a medical management program utilized to help BIDPO physicians achieve the performance targets included in the contracts negotiated with BCBSMA, HPHC, and THP, and to provide high quality, cost efficient care to their patients. Our nine Community Nurse case managers work with BIDPO PCPs (assigned by pod) and their patients who are covered under managed care plans.

Goals:

  1. Improve clinical care, quality and patient satisfaction by supporting the PCPs in meeting/exceeding targets on the BCBSMA AQC, HPHC, and THP process, outcome, and patient experience measures.
  1. Reduce potentially avoidable readmission rates by improving the transition of care from hospital to home.
  1. Provide individualized care management to patients at high risk for hospitalization or other high cost resources and who would benefit from more intense care management
  1. Help the PCP focus on clinical care by reducing the non-clinical and clinical workload that does not require a physician’s training and skill by working directly with patients and key office staff on the points listed above.

Specific Responsibilities:

  1. Track and monitor individual process and outcome measures for eligible HMO Blue, HPHC, and THP patients who have chronic diseases such as diabetes, cardiovascular disease, and depression.
  1. Utilize Quality Manager (Healthcare Data Services software) to enter and manage data, monitor PCP and practice performance, and plan needed interventions to ensure patients receive the required testing and medical management to promote optional health and clinical outcomes.
  1. Review patient registries with PCPs to determine which patients need to be brought in for medical management, or who may need telephone outreach.  Facilitate appointment scheduling, provide telephone outreach, patient education.
  1. Develop key clinical and administrative office contacts within the practice with whom to collaborate on data verification and patient outreach.
  1. Participate in meetings with BIDPO Leadership, Pod Leaders, and practices to review Pod performance data and to develop strategies for intervention.
  1. Perform and required audits and submit data corrections to the payor.
  1. Provide post discharge telephone calls (PREPARE – Project to Reduce Potentially Avoidable Readmissions) to all HMO Blue patients admitted to BIDMC and other community or tertiary hospitals.  Ensure that discharge instructions are understood, perform medication reconciliation, ensure appointments are scheduled, etc.
  1. Provide telephonic care management to high risk patients identified by Ingenix or PCP referral.  May include patients with multiple co-morbidities, or those with certain chronic conditions.
  1. Orient new BIDPO PCPs and their office staff to BIDPO policies, procedures, and resources (e.g., Anvita, NEHEN Express, BIDPO Website).