Medicare Plus Blue PPOSM offers enhanced care management programs to members. Our care management strategy begins with the Care Transition to Home team reaching out to assist in discharge planning for members and coordinating short-term care management. Members may be identified for programs including chronic condition management, complex chronic condition management, case management or oncology management. BCBSM may contact you, as the primary provider, to inform and coordinate care for these members if warranted. We discuss these programs in greater detail in the Medicare Plus Blue PPO manual (PDF).
Care Transition to Home
The Care Transition to Home team also acts as a triage area for members who may benefit from continued care management. If the member has ongoing needs that meet criteria for one of the advanced intensity programs, the team will refer that member accordingly. All other members are provided with discharge instructions and information on self-management.
Case management program
The Case Management Program assists members identified and referred by Care Transition to Home as having complex health issues and needs for coordination or intervention. Services include nurse-driven case management by phone or in-person to coordinate care needs and proactively identify and close care gaps. Nurse case managers may contact providers directly to coordinate care and services. Support services are provided until care gaps are closed and no additional case management benefit can be derived.
Chronic condition management program
Administered by Alere®
The Chronic Condition Management Program is a comprehensive disease management program designed to aid members in managing their chronic conditions. The program focuses on these conditions: chronic obstructive pulmonary disease, coronary artery disease, diabetes and heart failure. Members in the program receive education about their health status, personalized information regarding their treatment options, self-management materials and support with monitoring and managing their condition.
Providers will receive alerts regarding their members' health. Physicians will have the opportunity to opt out of having their patients participate in the program.
Note: Available to all Medicare Plus Blue PPO members.
Oncology case management program
Administered by KePRO®
The Oncology Case Management Program supports members who have been diagnosed with a cancer-related condition (skin cancer is excluded). Once referred by the provider, KePRO will reach out to the member to ask if they would be interested in the program. This program has been tailored to target and supports the needs of members with cancer by:
- Ensuring quality of care
- Providing access to care
- Offering advanced illness counseling and education
- Providing assistance with managing the physical and psychological aspects of cancer
Note: This program won't be available after Jan. 1, 2014.
Complex chronic condition management program
The Complex Chronic Condition Management Program is a hybrid case and disease management program customized to support members with multiple chronic conditions or complex care needs for members with:
- Coronary artery disease
- Chronic obstructive pulmonary disease
- Heart failure
Case managers provide support to these members over the phone to:
- Establish a treatment plan
- Ensure coordination of care
- Improve health status
- Reduce emergency room visits and hospital admissions
- Reduce gaps in care
Behavioral health case management program
Behavioral health case managers work with members and providers to coordinate mental health and substance abuse care. Services include:
- 24/7 availability of case managers
- Coordination of discharge needs
- Post discharge care
Note: All mental health and substance abuse inpatient, partial hospital, and intensive outpatient treatment admissions or extensions require prior authorization and concurrent review.
Quit the Nic
Quit the Nic is a telephone-based tobacco cessation program designed to support member in their efforts to stop smoking. Members have access to counseling with registered nurses. The program's goal is to improve the members' quality of life as well as reduce costs and hospital utilization for conditions associated with tobacco use.
The 24-hour Nurseline is a 24/7 telephone triage and health information service. Nurses maintain client confidentiality, while providing support, and if necessary, referring members to appropriate resources for further information. Support is provided on symptom management, provider searches, clinical support, education and referrals to community resources.
Health and Wellness
Our health promotion and wellness programs give members health information to help them understand their health care issues, address concerns and work more closely with their providers. Members can view online articles, tools and quizzes that provide information on numerous topics. Providers may refer members to this resource, when appropriate, by having them visit the Health and Wellness screen on their account at bcbsm.com. Members are encouraged to access this site and complete the confidential Health Assessment within 90 days of initial enrollment with Medicare Plus BlueSM. Information obtained is used to support continuity of care through care management program identification and BCBSM program development.
For questions about our care management programs or if you feel your patient would benefit from one of our programs, call the Provider Inquiry department at 1-866-309-1719. Nurse case managers may contact you directly to coordinate care and services.