Care and disease management

Blue Cross has reimagined care management to deliver a holistic, member-centric approach to coordinated care delivery where it’s needed most. The Blue Cross Coordinated Care program includes the use of enhanced analytics to identify the members who need it the most, and a multi-disciplinary care team to support their care needs.

Blue Cross Coordinated Care Program features include:

  • Robust analytics and enhanced data sets (e.g., social determinants of health) that allow Blue Cross to target the most members. We use reactive analytics to identify members who are already at high risk and clinically complex based on observed conditions, utilization and risk factors. Predictive analytics are also used to identify members who are likely to rise in risk or costs based on early indicators or potential future needs.
  • Integrated care teams, led by a nurse care manager, that include social workers, behaviorists, pharmacists, physician consultants and dietitians who focus on specific geographic regions to enable more community-centric care.
  • App-based digital technology that connects members to relevant care information through the channel of their choice – digital chat, text or email.
  •  A dedicated clinical team evaluates every high-cost member to confirm appropriate care, identify opportunities for intervention and make referrals as needed.

Care Planning Process

The Blue Cross Coordinated Care member-centered, care management program supports members to make informed decisions and successfully manage their own health by being an active participant in the care planning process. Once the member assessment is complete, care managers will develop comprehensive plans for each member including interventions, goals, barriers and measurable outcomes. The care plan will include medical, behavioral and psychosocial care goals to meet the member’s needs.

Care managers will ensure that the care goals reflect member, physician, caregiver and nurse input. Prioritization of the care goals will be done in tandem with the member based on clinical guidelines and motivational interviewing techniques. When applicable, the care plan will also be supplemented by input from the multidisciplinary team including pharmacists, social workers, behavioral health specialists and dietitians.

Coordination of Services

Coordination of services involves deliberately organizing the member’s care activities and sharing information among all the participants concerned with that member’s care to achieve safer and more effective outcomes. One of the key tenets of the Blue Cross Coordinated Care program is to provide coordination of services to our members to reduce fragmentation. Our program includes an integrated care team led by a nurse care coordinator who serves as the single point of contact for members and their families.

The nurse care manager is responsible for the coordination of medical, social and behavioral services for each member. Through the nurse care coordinator, members have access to a medical director when physician expertise is required, non-clinical support for care coordination and administrative tasks, pharmacy support and behavioral health support.

This comprehensive team works to manage the member’s care. Members also have access to a dietitian for nutrition education and a social worker for support in obtaining community resources to address the social and environmental factors that determine health (transportation, food, etc.). Furthermore, care teams are regional to allow enhanced coordination with local providers and community resources and increased ability to address social determinants of health.

Discharge Planning

All members at risk of readmission receive outreach within 48 hours of discharge. We work with these members to ensure a smooth and successful transition. Goals of this program include:

  • Provide education on clinical warning signs
  • Discuss and encourage adherence to treatment plan/discharge instructions
  • Assist members in scheduling follow-up appointments with their treating physician
  • Educate members on the importance of medication adherence
  • Assess member’s social determinants of health
  • Assess member for behavioral health needs
  • Connect members with treating providers and services

Case Management

Case management is part of our Blue Cross Coordinated Care program. Blue Cross uses robust analytics and enhanced data sets (e.g., social determinants of health) that allow us to target the most impactable members. We use reactive analytics to identify members who are already at high risk and clinically complex based on observed conditions, utilization and risk factors. Predictive analytics are used to identify members that are likely to rise in risk or costs based on early indicators or potential future needs.

Once members are identified, they are prioritized based on indicators that will be addressed by the program. Members are then assigned to our integrated care team for outreach.

Disease Management

Disease management, also part of the Blue Cross Coordinated Care program, identifies members with chronic conditions (heart failure, COPD, CAD and diabetes) and addresses their needs in a holistic manner.

Interventions include:

  • Addressing gaps in care
  • Encouraging member/primary care physician relationships
  • Helping members build self-management skills
  • Support members with barriers related to social determinants

Coordination with Physicians

The Blue Cross Coordinated Care program is designed to support providers give the best possible care for their patients. A multidisciplinary, integrated team provides holistic care management to members across their health needs.

This team supports provider-delivered care by:

  • Assisting members with scheduling medical appointments.
  • Following up with members after doctor’s appointments to reinforce the importance of adhering to treatment plans.
  • Providing condition-specific education to members with chronic and complex care needs.
  • Co-managing members participating in Provider Delivered Care Management programs to support the prescribed treatment plan when applicable.

To support patient care, a member of the team will let the primary care doctor or specialist know if one of their patients is participating in the care management program. The program isn’t intended to replace the doctor-patient relationship in any way.

Diabetes Management

The Diabetes Management program focuses on high-risk and newly diagnosed members with diabetes. Certified Diabetes Educators (CDEs) deliver a highly targeted intervention to improve self-management and medication adherence. Throughout the program, CDEs follow-up with patients to see how they are faring, keeping in touch via multiple communication methods — phone calls, texts, emails, etc. To enhance learning, the coaching experience is reinforced by online videos, educational content and online peer-to-peer support.

Note: The Diabetes Prevention Program is for members who have NOT been diagnosed with diabetes but have certain risk factors.

Behavioral Health Care Management

Blue Cross provides care management services as part of our Blue Cross Coordinated Care program to assist members who may benefit from additional support due to complex behavioral health care issues or co-existing behavioral and medical health conditions.

Identified members are contacted by telephone. Following the members’ consent to participate in the program, the care manager completes an assessment, develops a plan of care that identifies targeted interventions and long- and short-term goals and notes any barriers to achieving the expected outcomes. Care management services are provided until the identified goals are met, the member declines further care management or no further benefit from care management can be identified.