Case Management/Transition of Care

• Facilitating conference calls between the member, the physician and the case manager as needed to clarify treatment plans, medication regimens or other urgent issues;
• Assessing the member’s daily living activities and cognitive, behavioral and social support;
• Connecting members and their families with professionals who can help them address medical, legal, housing, insurance and financial issues facing older adults;
• Assisting members to obtain home health and durable medical equipment;
• Monitoring medication adherence;
• Assessing the member’s risk for falls and providing all-prevention education;
• Helping caregivers access support and respite care;
• Arranging access to transportation; and
• Referring members to meal delivery programs and advance directive preparation services.

The Case Managers work closely with members in the DHCS Enhanced Case Management (ECM) program and D-SNP Medicare members. 

Chronic conditions addressed through our case management program include but are not limited to chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, hypertension, HIV/AIDs, asthma and diabetes.

All case management cases including care plans and actions are housed in an internal platform which integrates with our core systems which allows integrated access by approved staff.