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Care management: improving quality of life while reducing medical costs

Key Takeaways

  • BlueCross certified care managers or coordinators assist members with chronic health conditions, mobility issues, mental health needs, or following an inpatient or outpatient hospital visit.
  • Our care managers and coordinators can help you schedule follow-up appointments, understand your medications, make home safety and transportation arrangements, and more.
  • These resources are built into your coverage so that BlueCross can help ensure you have peace of mind on your journey to better health.

At BlueCross, we’re a partner on your journey to better health and wellness, whether through promoting preventive health care benefits or protecting you when unexpected health expenses arise.

If you or a loved one find yourself in a situation where you need medical guidance after you’ve received outpatient or inpatient care, BlueCross will be on your side in a hands-on way.

“We provide a bridge to health care that can help improve quality of life, and that includes looking at any barriers to that access,” says Patricia Jones, director of clinical strategy at BlueCross. “For example, if our members aren’t able to easily get to the doctor, we look at how we can make that possible.”

BlueCross Patricia Jones
Patricia Jones, director of clinical strategy at BlueCross, helps lead our efforts to transform health care spending to benefit our members.

From there, we support members through the care delivery process in more complicated scenarios.

“We’re not just managing a case or a widget,” Patricia says. “We’re providing a support system for members by embarking on a journey with them.”

This support comes from a real person at BlueCross and is personalized to your needs. The goal is twofold: to help improve your health today and prevent frustrating, expensive experiences down the road as you navigate follow-up appointments, medications and seeing new providers.

Our turn at the wheel

The care management component is applied to each of our membership populations. BlueCross currently employs more than 850 registered nurses, many of them in care management.  Depending on the medical situation and services needed, members in need may work closely with a care manager or a care coordinator.

The difference between the two is fairly simple.

A care manager typically works with a member on a shorter-term timeline; say, if the member has a treatable condition that involves fairly complex care and cooperation from more than one provider. A care manager facilitates the necessary communication between all parties involved.

A care coordinator, part of a long-term support system, also juggles communication and scheduling logistics between multiple providers, but is typically involved with members who have chronic conditions and require hands-on assistance from direct support professionals. A care coordinator helps ensure a member’s home is suitable for personally managed care and visits the member in the home to assist with mobility issues and disease management. A care coordinator is also assigned to a member for the entire time he or she is enrolled in the program.

Experience is key

Our care managers and coordinators are required to have at least five years of clinical nursing experience.  This means that they not only understand the general practices of medicine, but already have the necessary hands-on skills when it comes to building trust and caring for patients.

“The best care managers and coordinators are often the nurses who have been in home health care or in hospice,” says Patricia, herself a registered nurse and certified case manager. “These nurses must be independent, as they don’t have the support around them like nurses in a hospital. They must have excellent time management, confidence in their skills, and a thorough understanding of the medical aspects of a patient.”

4 kinds of care management

The specific responsibilities of care managers and coordinators can vary depending on the population they serve. Consider these scenarios where we can be a resource as well as an advocate for your wellbeing.

  1. Transition of care

Available to all of our members, transition of care involves care managers reaching out to a member after an inpatient stay to provide immediate assistance with their health care needs, thereby reducing the likelihood of hospital readmission.

The results of this transition are twofold: to improve quality of life while reducing medical costs.

Oftentimes this involves long-term follow-up care for issues like open wounds or car accident recovery.

Care managers work closely with medical providers (primary care physicians, hospital discharge planners, etc.) to ensure a safe and comfortable transition home. They also direct you to in-network providers for the best use of benefits, assist with follow-up appointments and review medications – specifically, providing education about taking your medications as directed to help with a rapid recovery – as needed.

BlueCross Kelly Hutchison
“I never had a person in my corner like that,” says BlueCross member Charles Henderson about his care coordinator, Kelly Hutchison.
  1. Complex care management

If you’re struggling with heart, kidney, lung or liver diseases or the aftermath of traumatic injuries, a care manager can provide guidance through medical policies, referrals and prior authorizations.

Other times, care managers may serve in an intervention capacity. For example, they might reach out to recommend a health assessment for a member who frequently visits the emergency room with chest and back pain. The care manager identifies depression and refers the member to the BlueCross behavioral health care team. From there, he or she collaborates with the behavioral health care manager team to address the depression and ultimately help the member become more physically and emotionally stable.

This prevents further emergency room visits and hospitalizations – or worse, a fatal home accident due to the complications of the medical and behavioral diagnosis.

Care Coordinator Manager
Care Coordinator Manager Sara Shular finds joy in connecting with members and helping make a difference in their lives.
  1. Behavioral health

As mentioned above, collaboration between this team and medical care management occurs regularly, but only upon referral from the medical side. Behavioral health care managers work with you to set specific goals, provide a variety of educational materials, and offer support to you and your family during your journey to improved mental health.

You can be referred for behavioral health services following a new diagnosis of depression or an old diagnosis where you may have neglected to take your medication as directed. Behavioral health care managers may direct you to community resources as needed. Coverage for inpatient behavioral health care and a crisis call line are available to you 24/7. 

BlueCross Dr. Natalie Tate
There are many links between behavioral health and addiction, which has contributed to the opioid epidemic. Dr. Natalie Tate, vice president of pharmacy management, oversees the efforts made by BlueCross to combat this crisis.
  1. Chronic care management

We want our members to overcome barriers to wellness and achieve their healthiest lives. If you have a chronic condition like asthma, diabetes, coronary artery disease or congestive heart failure, you can be referred to our chronic care management team.

These care managers help stabilize your health status, assist with self-managing your condition, and promote healthy lifestyle changes designed to improve quality of life and reduce risk factors. Depending on your risk level, you may receive different forms of outreach and engagement.

BlueCross Brenda Jones
Brenda Jones, a BlueCross-employed patient-centered medical home care coordinator, speaks with a member she serves at Fayetteville Medical Associates.

Chronic care managers also encourage members to pursue the full spectrum of care. For example, if you have diabetes, a care manager may advise you to get a vision exam. Many members who don’t have routine vision insurance may not realize that their medical benefits cover a vision exam if it pertains to a medical diagnosis.

An ongoing journey

All care managers and coordinators work to ensure you receive the appropriate level of services and support , and to determine whether certain services should be increased or decreased.

Let’s say you’re homebound with a set number of “home health” hours per month with your care coordinator. He or she may determine that, due to worsening health conditions, you need more in-home hours per month.

“Our care managers and coordinators work with you one on one, whether it be over the phone or face to face in a health facility, office or home setting,” Patricia says. “They come from a place where there is no judgment and build trusting relationships. Some members even feel compelled to share health information with them that they don’t share with their loved ones.”

Welcoming a copilot

Care managers and coordinators can also connect you with resources to assist with everyday needs  such as healthy food options, home repair/modifications, medical equipment, prescription assistance, utilities and transportation.

According to Patricia, oftentimes the biggest obstacle to overcome is the willingness to accept help from a stranger – even one who has your best interests at heart.

“Care management is a benefit plan resource we encourage you to take advantage of,” she says. “There’s a stigma that comes with the word ‘management’ and some members may fear the loss of independence. We understand those concerns, but hope the ultimate takeaway is that your health – individually and collectively – is our biggest concern.”

About Jesse Thompson, Senior Communications Specialist

A photo of the authorJesse joined the BlueCross BlueShield of Tennessee corporate communications team in 2017. A Chattanooga native, he has more than 15 years’ experience in content creation, management, and strategy for consumer audiences, including a six-year stint in health care marketing.

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