Discharge Outreach Call Program. The Discharge Outreach Call Program assists members in understanding their post-discharge treatment plan and thereby helps prevent avoidable complications and readmissions. Within two (2) days of discharge from a Hospital, a Keystone nurse may contact a member by telephone to discuss any discharge concerns; to assess the member’s understanding of and adherence to the provider’s discharge instructions, including the timing of any follow-up appointments; to determine the member’s understandings about any medications prescribed; and to make sure any necessary arrangements for services, such as home health care, are proceeding appropriately.
Discharge Outreach Call Program. The Discharge Outreach Call Program assists members in understanding their post-discharge treatment plan and thereby helps prevent avoidable complications and readmissions. Within two (2) days of discharge from a Hospital, a Keystone nurse may contact a member by telephone to discuss any discharge concerns; to assess the member’s understanding of and adherence to the provider’s discharge instructions, including the timing of any follow-up appointments; to determine the member’s understandings about any medications prescribed; and to make sure any necessary arrangements for services, such as home health care, are proceeding appropriately. Case Management Program The Case Management Program is a service for members with complex medical needs or who may be at risk for future adverse health events due to an existing medical condition or who may require a wide variety of resources, information, and specialized assistance to help them manage their health and improve their quality of life. The program assigns an experienced Keystone Case Management nurse or coordinator to a member or family caretaker to help make arrangements for needed care or to provide assistance in locating available community resources. Case Management services provided to members are numerous and are always tailored to the individual needs of a member. Participation in Keystone’s Case Management Program is voluntary and involves no additional cost to our members. Services often include, but are not limited to: • Assistance with coordination of care; • Discussion of disease processes; • Facilitating arrangements for complex surgical procedures, including organ and tissue transplants; • Facilitating arrangements for home services and supplies, such as durable medical equipment and home nursing care; or • Identification and referral to available community resources, programs; or organizations. DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA Utilization Review and Criteria for Behavioral Health Services Utilization Review activities for behavioral health services (Mental Health and Substance Abuse services) have been delegated by the HMO to its contracted behavioral health management company which administers the behavioral health Benefits for the majority of the HMO's Members. Members seeking Mental Health care and Substance Abuse services may obtain Preauthorization for such services from the contracted behavioral health management company. DISEASE MANAGEMENT PROGRAMS The Disease M...
Discharge Outreach Call Program. The Discharge Outreach Call Program assists members in understanding their post-discharge treatment plan and thereby helps prevent avoidable complications and readmissions. Within two (2) days of discharge from a Hospital, a Keystone nurse may contact a member by telephone to discuss any discharge concerns; to assess the member’s understanding of and adherence to the provider’s discharge instructions, including the timing of any follow-up appointments; to determine the member’s understandings about any medications prescribed; and to make sure any necessary arrangements for services, such as home health care, are proceeding appropriately. Transition of Care Program This program addresses the needs of Members who have been discharged from an acute care facility. Through the use of an automated outbound calling system, an initial screening is completed on all Members with an acute hospital stay resulting in discharge to their home. We address changes to medications, follow-up lab and imaging appointments, and physician follow-up appointments to ensure smooth transitions to home and outpatient care and minimize the potential for readmission. Depending on the member’s answers to the screening questions, which will identify potential areas of concern, members are referred on to the DOC Program for additional assessment and follow up by the DOC nurse. Emergency Room Utilization Program This program provides an integrated care management approach for Members who have had an emergency room (ER) visit and were not subsequently admitted to an acute inpatient facility. Members will receive an automated outbound telephone call to provide educational information related to available alternative care options. Alternative care options include Capital BlueCross’ Nurse Line, the Member’s primary care provider office, and Urgent Care Centers. The educational telephone call is not to discourage utilization of the ER, but to provide education on the use of alternative care options when appropriate. Members will be asked if they have a primary care provider. If they do not, assistance in locating either a primary care provider or an Urgent Care Center will be offered. The Capital BlueCross website and Customer Service telephone number also will be offered. Additional follow-up telephone calls along with more intensive assessments will be made to Members with multiple ER visits. Referrals to a care management program will be made where appropriate. DELEGATION OF UTILIZATION REVI...
