Program overview: 

Members are considered eligible for case management services if they demonstrate one or more of the following care needs:

• Advanced illness or end-of-life care needs (excluding hospice unless previously engaged with case management)
• Brain injury (traumatic or anoxic) – referred to a specialized Case Management Program
• Uncontrolled co-morbidities
• Physician or member referral
• Urgent socio-economic challenges (e.g., safety concerns, lack of electricity, food insecurity, transportation barriers)
• Unmet discharge needs (e.g., inability to fill prescriptions)
• Discharge involving new durable medical equipment (e.g., oxygen, ventilator, hospital bed)
• Non-compliance with treatment plans (e.g., missed medications or appointments)
• Limitations in daily activities or frequent absences from school/work
• Knowledge gaps regarding diagnosis or disease process requiring education and support
• Bariatric surgery with high strategic risk scores
• Need for Private Duty Nursing
• Any other situation deemed appropriate by clinical judgment