Medical management

Care managers are nurses or behavioral health professionals who create care plans that help members meet their goals. They help members learn how to manage their health conditions and meet their health care needs. 

The primary goals for care management are to:

• Support members who require care coordination

• Effectively transition members from one level of care to another

• Streamline, monitor and adjust care plans based on progress and outcomes 

• Reduce hospital admissions and unnecessary emergency department and crisis service use

• Ensure members have the proper tools to self-manage care so they can safely live, work and integrate into the community

• Assess social determinants of health (SDOH) needs and make referrals, as needed 

A goal specific to our members with serious mental illness (SMI) is to identify those at the top tier of high risk and cost. We want to determine which of these members would benefit from an intensive level of care management in a fully integrated health care program.

Not all members need complex care management, so we created criteria to determine who may benefit the most. 

Check these criteria:

• Do they frequently use the ER instead of visiting your office for ongoing issues?

• Have they recently had multiple hospitalizations or transitions of care?

• Are they having trouble getting medical benefits you ordered?

• Are they poorly managing chronic comorbid conditions?

• Have they been diagnosed with congestive heart failure, diabetes, asthma or chronic obstructive pulmonary disease, yet don’t comply with the recommended treatment?

• Do they need help applying for ALTCS?

• Do they have HIV?

• Are they pregnant with high-risk conditions?

• Are they a pregnant teen?

• Are they pregnant and over 35 years of age?

• Have they received a referral to a specialist, but are unsure of the next steps?

• Are they a member of Mercy Care ACC-RBHA with SMI and require Special Assistance according to the Division of Behavioral Health Services Office of Human Rights and Mercy Care provider manual?

Complete the right form and email it to us based on the type of member or plan:

• Members who are pregnant: Email a completed perinatal referral form (PDF).

• Members having issues with medicines that have potential for misuse: Emal Exclusive Prescriber Program a completed Exclusive Prescriber Program referral form (PDF).

• Members of Mercy Care ACC-RBHA with SMI: Email Care Management Referral a completed care management referral form (PDF).

• Members without Medicare: Email Care Management Referral a completed care management referral form (PDF).

• Mercy Care Advantage members: Email Mercy Care Advantage Care Management Referral a completed care management referral form (PDF).

What happens after a referral

After you make a referral, care management triage staff at Mercy Care reviews the case and decides whether to assign a care manager. They may also refer the member to another area for help. Since we’re not able to provide care management to everyone, we use predictive modeling software to help determine the need.

For members of Mercy Care ACC-RBHA with SMI 

Care managers work directly with the member’s providers to coordinate care. The care manager will complete a comprehensive case analysis review (CAR) that includes:

• A medical chart review to identify the member’s current health status, current provider’s service utilization and specific gaps in care

• Consultation with the member’s treatment team

• Review of administrative data, including claims and encounter data

• Demographic and customer service data

• Root cause analysis as to over- or under-utilization of services

• Medication review, including updating a member’s medication list

• Placement review, including updating a member’s placement history

Care managers use information from the CAR to develop a streamlined member-centric plan of care that supports the member’s:

• Physical and behavioral health

• Social and community service needs

• Placement goals, preferences and barriers

For all other Medicaid members

Care managers contact members to schedule time for an assessment. They ask members about their health, as well as resources they use. These answers give care managers a better understanding of what help members need most.

Next, members and care managers work together to make a care plan. The care manager also educates members about how to get the care they need. They may also talk with members’ health care providers to coordinate care. Once members meet their care plan goals, they complete care management. If they need care management in the future, we can reopen the program for them.

Call 2-1-1 in Arizona or 1-877-211-8661 (TTY 711 or 1-800-367-8939) from anywhere to help members with food, housing, jobs, rides and other community resources.

Or visit 2-1-1 Arizona.

We have a comprehensive ongoing Quality Management and Performance Improvement (QM/PI) program that:

• Focuses on the quality of clinical care and services to our members

• Helps ensure that members get preventive health care in a timely manner 

• Provides care management services to people with special health care needs 

• Adheres to state and federal requirements 

• Is overseen by the Governing Board of Directors and Quality Oversight Committees  

Performance improvement and measurement are fundamental to the QM/PI program. We can’t improve what we don’t measure. So, we analyze encounter data to identify gaps in care and recommend opportunities for improvement. Your involvement, feedback and recommendations for improving the delivery of care and services are welcome. Just contact us.