Case Management
What is Case Management?
Case management at Confluence Health is a collaborative process between case management staff and other clinical teams to provide proactive care management to patients with an emphasis on identifying risks to prevent escalations of care. Case management offers chronic disease management education and care coordination, assists with closing patient care gaps, and works to identify social determinates of health and appropriate resources to meet those needs.
How to Refer to Case Management
Anyone can refer a patient for services. Please call (509) 433-3010 (referral line) and leave a message stating the reason for your call and your call-back information. Someone from our department will return your call within 24 business hours.
Current Case Management Programs
Chronic Care Management & Principal Care Management (CCM & PCM)
Description of Service:
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A comprehensive care plan that addresses the conditions that qualify the patient for services will be established, implemented, revised, and monitored through direct and indirect contact with a personal RN case manager. The focus will be on setting small measurable and achievable goals with the patient to empower them to take ownership of and improve their overall health.
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Health education, coaching, and patient centered interventions to motivate for overall health improvement.
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Assistance with coordination of visits with other providers, facilities, labs, radiology or other testing.
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Assistance with management of medications.
Who Qualifies for Services:
Medicare patients who meet the following criteria:
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Has one or more chronic conditions expected to last at least 12 months, or until the death of the patient.
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Chronic condition(s) places the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
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Has a primary care provider at Confluence Health.
Cost:
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There are no case management fees for this service.
Premera Case Management
Description of Service:
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A comprehensive care plan that addresses the conditions that qualify the patient for services will be established, implemented, revised, and monitored through direct and indirect contact with a personal nurse case manager. The focus will be on setting small measurable and achievable goals with the patient to empower them to take ownership of and improve their overall health.
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Health education, coaching and patient-centered interventions to motivate for overall health improvement.
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Assistance with coordination of visits with other providers, facilities, labs, radiology or other testing.
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Assistance with management of medications.
Who Qualifies for Services:
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Any Premera patient with a primary care provider at Confluence Health.
Cost:
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There are no case management fees for this service.
Pediatric Case Management
Description of Service:
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Health education, coaching, and patient-centered interventions to motivate for overall health improvement.
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Assistance with coordination of visits with other providers, facilities, labs, radiology or other testing.
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Assistance with management of medications.
Who Qualifies for Services:
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Any pediatric patient (age 0-17) with a primary care provider at Confluence Health.
Cost:
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There are no case management fees for this service.
Annual Wellness Visit (AWV)
Description of Service:
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Through a team-based approach with the nurse case manager and the primary care provider, the Annual Wellness Visit (AWV) is intended to help people with Medicare maintain good health by catching signs of disease early on and taking a preventive approach to healthcare.
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During the AWV intake, a nurse case manager will screen for potential patient safety issues such as fall risk, home safety, hearing and vision, cognitive status and more.
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The nurse case manager will assess for challenges the patient may face regarding housing, transportation, finances, etc. and provide appropriate community resources as indicated.
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The nurse case manager will also assess for CCM eligibility and appropriateness and refer if indicated.
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With patient input, the nurse case manager will develop a personalized plan of care for the patient, which includes Medicare-covered services, immunizations, screening labs and imaging that may be available.
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The provider will review with the patient the personalized plan of care that was developed, discuss any questions the patient may have, and will approve and sign off on appropriate orders that were placed.
Who Qualifies for Services:
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Any patient with Medicare part B or Medicare Advantage plan as their primary insurance.
Cost:
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Free! This visit is covered once yearly (every 366+ days) through the patient’s Medicare part B coverage.
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Note: There may be labs ordered by the provider as a result of this visit, where normal costs associated would apply.
Transitions of Care Management (TCM)
Description of Service:
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Transitions of care management works to identify barriers or risk factors post-hospital discharge to prevent readmission.
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The TCM case management team contacts patients post discharge to assess their status, review their current medications on file, discuss their support system, evaluate the need for durable medical equipment or other supplies, and ensure a proper follow-up with the primary care provider or surgeon has been scheduled.
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The TCM will also assess for post discharge complications and assist with care coordination when indicated.
Who Qualifies for Services:
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Any patient discharged from an inpatient status from Confluence Health Hospital and any patient with a primary care provider at Confluence Health that discharges from Mid-Valley Hospital or Samaritan Healthcare.
Cost:
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There are no case management fees for this service.
Total Joint Case Management
Description of Service:
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The total joint nurse case management team will work with patients from pre-op through 30 days post operatively.
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The pre-op intake assessment completed with the total joint case manager assesses current patient status and readiness for surgery, provides education for what to expect post operatively, assesses patient support system, and provides proactive planning for post-surgical needs of durable medical equipment.
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The total joint case manager will continue to follow and check in with the patient for 30 days post operatively, focusing on infection prevention, recovery and avoidance of hospital readmission.
Who Qualifies for Services:
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Any patient referred for a total knee or total hip procedure within Confluence Health.
Cost:
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There are no case management fees for this service.
HIV Case Management
Description of Service:
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Staff provides medical and social case management services (including linking clients to needed resources) to help reduce barriers to medical adherence and help them achieve viral suppression.
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Staff provides support, health education and patient-centered intervention to motivate for medical adherence and achievement and maintenance of viral suppression.
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Case mangers complete a comprehensive assessment of patient status and needs for all patients coming into the program. The case managers will also develop an individualized service plan (care plan) with actionable steps to work toward goal achievement.
Who Qualifies for Services:
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Any patient residing in Washington State with an HIV/AIDS positive diagnosis who is not currently receiving HIV case management services through another organization.
Cost:
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This is a grant-funded program through the Department of Health.
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There are no case management fees for this service.
Multi-Visit Patient program (MVP)
Description of Service
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Through a collaboration with multiple specialties, this team meets once per month to review our highest Emergency Department (ED) utilizers to discuss these cases for ED appropriateness.
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If inappropriate use is determined, this team will dive deeper into the clinical, behavioral and social drivers that may be contributing to those ED visits and what other potential resources may be implemented to better support these patients outside of the ED setting.
Who Qualifies for Services:
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Any patient with multiple ED and/or hospitalizations within the past 12 months.
Cost:
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There are no case management fees for this service.
Social Work
Description of Service:
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Social workers will work with patients referred to identify any social related needs and will link patient to appropriate services and resources.
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Social workers will partner with patients to support and empower them to address needs and barriers identified in order to move toward overall wellness.
Who Qualifies for Services:
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Any patient within Chelan, Douglas, Grant or Okanogan counties who has been identified with social determinants of health needs can be referred for this service.
Cost:
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There are no case management fees for this service.
