Please fax completed form to: Care Management Department (951) 280-8203 Choose Program Type check Program type and items that apply for member – Episodic Care Management Complex CM (CCM) Disease Management Social Worker - Requires less than 60 days of care Requires greater than 60 days CHF COPD Social/behavioral needs only of care. For member with 5 or more inclusion criteria Long term Care Management Med Management Transition of Care - Care Coordination – – May require more than 60 days of High risk/high cost medication Intervention focused on Assistance with appointments, care prescribed. Episodic Care member that is transitioning DME across levels of care Inclusion criteria 2 or more active chronic Sudden disability such 2 or more unplanned Assistance in obtaining diagnoses; CHF, COPD, ESRD, as; transplant, admissions/6 months community resources CKD 4-5, CRF, Oncology with trauma, spinal cord metastasis (excluding breast, injury prostate or thyroid) Sudden catastrophic diagnosis Four or more daily 2 or more ED visits/6 Home environment such as ALS, Guillain-Barre, medications months evaluation for potential surgical oncology, traumatic ADL deficits brain injury History of non-adherence with Referred by PCP for 2 or more 911 calls/ 6 Patients who have plan of care assessment and months reached the prescription coordination of care coverage gap (donut hole) Caregiver issues Receiving ongoing care 3 or more DME items Loss of spouse at tertiary care/OON providers Placement Issues Unstable living situation 2 or more behavioral Financial distress health admits/6 months Diagnoses For Questions Regarding Referrals, call the Ambulatory Care Management Team at (951) 280-7819
Choose Program Type – check Program type and items that apply for member Episodic Care Management Requires less than 60 days of care Complex CM (CCM) Requires greater than 60 days of care. For member with 5 or more inclusion criteria Disease Management CHF COPD Social Worker - Social/behavioral needs only Long term Care Management May require more than 60 days of care Med Management – High risk/high cost medication prescribed. Episodic Care Transition of Care - Intervention focused on member that is transitioning across levels of care Care Coordination – Assistance with appointments, DME Inclusion criteria 2 or more active chronic diagnoses; CHF, COPD, ESRD, CKD 4-5, CRF, Oncology with metastasis (excluding breast, prostate or thyroid) Sudden disability such as; transplant, trauma, spinal cord injury 2 or more unplanned admissions/6 months Assistance in obtaining community resources Sudden catastrophic diagnosis such as ALS, Guillain-Barre, surgical oncology, traumatic brain injury Four or more daily medications 2 or more ED visits/6 months Home environment evaluation for potential ADL deficits History of non-adherence with plan of care Referred by PCP for assessment and coordination of care 2 or more 911 calls/ 6 months Patients who have reached the prescription coverage gap (donut hole) Caregiver issues Receiving ongoing care at tertiary care/OON providers 3 or more DME items Loss of spouse Placement Issues Unstable living situation 2 or more behavioral health admits/6 months Financial distress Diagnoses Please fax completed form to: Care Management Department (951) 280-8203 For Questions Regarding Referrals, call the Ambulatory Care Management Team at (951) 280-7819