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Complex Case Management

eQHealth Solutions Complex Case Management Program is designed to assist members experiencing a catastrophic event, acting as their advocate, assisting with coordination of care and optimizing benefit utilization. This is done through the development of a timely case management plan that strives to get the member to optimal health and achieve quality outcomes in a cost-effective manner. Complex Case Management staff ensures that the right services are being performed at the right time, at the right level of care, and within the member’s benefit plan. 

Core Program Elements:

  • Providing a comprehensive, holistic assessment of the member, their benefit plan and long-term goals and health care needs
  • Facilitation of discharge transition to the appropriate level of service
  • Alignment and coordination of post-discharge needs with the physician treatment plan and within the member benefit structure
  • Development, implementation and ongoing monitoring of an individualized plan of care
  • Optimizing the use of in-network providers
  • Facilitation of rate negotiations when indicated
  • Facilitation of life care planning when indicated

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At-a-Glance: Complex Case Management Program Overview

  • Referrals & Member Enrollment: Referrals are triggered by a catastrophic event such as primary diagnosis for a severe, high-cost disease, injury or a new onset rare condition. Frequently, there is a compounding factor of psychosocial or behavioral health needs as well.  Interventions are focused on resolving the immediate needs of the acute and post-acute period.
  • Enrollment Timeframe: Members are typically enrolled for a period of no longer than 90 days post hospital discharge.
  • Diagnoses Covered: High-risk pregnancy, NICU babies, transplants, catastrophic illness (such as cancer,  aneurysms, multiple sclerosis, ALS, etc. that are high-cost and high-risk to the member); multiple trauma (such as severe motor vehicle accidents, severe head injury, severe strokes requiring coordination of multiple services and physicians) or other catastrophic events.
  • Mode of Care Coordination: Telephonic outreach.
  • Clinical Quality Measures: HEDIS® measures and specific guidelines for conditions such as diabetes, heart failure, COPD, etc.
  • Outcome Measures: Population health, clinical, & financial measures. Customer satisfaction will be measured for members and providers.

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Why Adopting a Complex Case Management Program is Important for Your Organization?

Complex Case Management is the coordination of care and services for those members experiencing a catastrophic event, many of which have multiple chronic conditions that have had an adverse event causing immediate medical attention. Taking care of the sickest members in your plan or organization is vital to overall plan performance and organizational success. Even more important is enhancing member quality of life and satisfaction. Complex case management is a care management model that has had proven results.

What Sets eQHealth Solutions' Complex Case Management Solution Apart From the Rest?

eQHealth Solutions offers an modern approach to managing members by improving care outcomes and touching the right patients at the right time to deliver the right level of care within the member’s benefit plan. The goal of the program is for the member to begin to regain optimal health and engage in the management of their own health. eQHealth’s Complex Case Management service offering can be sold as a standalone solution or bundled with our Medical Management comprehensive offering, giving our clients exactly what they need to reach their organizational goals for quality outcomes and cost reductions. Additionally, as part of our solution, you have access to our innovative Population Health Management technology that is second to none in managing your population, clinical, and financial measures.

Have any questions? Call us toll-free.1-800-720-2578