Case Management/Transition of Care
By communicating MedPOINT’s Case Management department consists of RNs, LVNs, social workers and other allied health workers. The dedicated case management staff are assigned to members with chronic conditions or other needs that require one or more of the following services:
- 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 in obtaining 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
- Referring members to meal-delivery programs and advance directive preparation services
All Medi-Cal newly enrolled SPD members and Cal MediConnect members will have a Health Risk Assessment performed within 4 days to identify the need for expedited services, eligibility in complex case management, risk factors, and health information.
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 Essette’s care management platform which integrates with our core systems. This allows integrated internal and external access by approved staff.
