HNE CM services are designed to support providers (primary care physicians and specialists) in managing members with complex acute or chronic conditions.  HNE Case Managers (registered nurses or certified social workers) assist providers in coordinating a variety of care and support services for members with serious medical and/or behavioral health conditions. An active partnership is created between the member, providers and the Case Manager.

Access to CM

HNE has multiple avenues for members to be considered for CM including the following referral sources: member/family, practitioner, health information line (NurseResponse), facility discharge planner, community resources, and the HNE UM process. In addition, HNE identifies members for CM through claims/encounter data, hospital discharge data, pharmacy data, data collected through the UM process (referrals at time of inpatient facility discharge), as well as other sources that may be available.

Member qualification for CM

The member must be an HNE member and agree to participate in CM interventions. Members have the right to decline participation or disenroll from CM programs and services offered by HNE at any time.

Process

Each member accepted into CM is assigned to an individual Case Manager who performs an in-depth assessment and works closely with the member , his/her PCP and treating specialist to coordinate a variety of care and support services.   The initial assessment of the member’s health status includes:

• Condition specific issues
• Clinical history including medications
• Assessment of activities of daily living
• Assessment of mental health status, including cognitive functioning
• Assessment of life planning activities
• Evaluation of cultural and linguistic needs, preferences or limitations
• Evaluation of caregiver resources
• Evaluation of available benefits

After the initial assessment, a CM plan is developed which includes:

• Development of a CM plan that includes both short and long term goals
• Identification of barriers to meeting goals or complying with the plan
• Development of a schedule for follow-up and communication with the member
• Development and communication of self management plans for members

Contact with Provider

The Case Manager communicates frequently with the member's PCP, specialists, and allied health providers in order to coordinate care and services.

Satisfaction with CM

HNE evaluates satisfaction with the CM program by obtaining feedback from members and analyzing member complaints and inquiries.  A practitioner satisfaction survey is being added in 2008.

How to Refer Members

Providers can refer members for these important services by calling the HNE Health Services Department at 800-842-4464, ext. 5027.