CMCS Connections

2 C M C S c o n n e c t i o n s 4 t h q u a r t e r 2 0 1 5 By cheryl stacey I t has been an exciting year for CMCS and 2016 promises more opportunity for innovation and program expansion. As CMCS expands our capabilities in data analysis and reporting outcomes, we will expand clinical programs into the community through an "embedded case manager model". This program, which places case managers within provider practices, has shown to be effective in reducing re-admissions, closing gaps in care, reducing length of stay and improving quality of care. In 2016, CMCS will begin to place experienced RN case managers in community based practice sites such as physician practices, community clinics, integrated hospital delivery systems and provider network offices. This model of care management builds on the strength of CMCS' experience, enhanced data analytics, a tested care management system and years of collaboration with health care providers in Indiana. The Embedded Case Manager (ECM) will provide case management services as an active and engaged team member collaborating with providers and other healthcare staff members. Experienced case managers will work with providers to coordinate health care and community services for members who have been identified as having gaps in care, or who may be at risk for costly care and are consequently enrolled in the program. Practice sites include but are not limited to: physician practices, community health clinics, health care facilities and provider networks. Individuals served by the ECM are assigned according to their needs and the agreed upon criteria established by CMCS and the provider entity. The ECM practices within the scope of his/her professional credentials as a member of an interdisciplinary team of healthcare professionals. Additionally, each ECM practices case management according to the professional process and philosophy defined by the Case Management S o c i e t y o f A m e r i c a . E C M s a r e employees of CMCS. O b j e c t i v e s o f t h e p r o g r a m a r e : 1. To ensure convenient access to high quality health services for members of any insurance who meet the criteria for eligibility in the program. 2. To provide professional case management services to individuals with complex health care needs, ambulatory sensitive conditions and those who may be at high risk for increasing care including an inpatient stay, if they are not compliant with guideline standards. 3. To support the active engagement of every individual with their Primary Care Physician. 4. To partner effectively with professionals and support personnel throughout the individual's assigned health care network, coordinating services to promote the efficient, effective delivery of appropriate services. 5. To provide health education and wellness services to support optimal wellness with an emphasis on self- management skills including tobacco cessation, medication adherence, weight management, healthy eating and other strategies related to their needs and chronic condition(s). 6. To support and direct individuals to use health system resources appropriately, diminishing the use of emergency room services for primary care services and avoiding preventable admissions, especially avoidable readmissions. 7. To provide inter-disciplinary care planning that supports the integration of medical and behavioral health and services. Direct access to the ECM is defined by the hours of operation at the care delivery site. CMCS' clinical documentation system, Care Connections, provides centralized documentation of the case management record. Additionally, the ECM has access to the member's EMR to support the treatment plan and maintain effective communication with care givers and the clinical team. Participation in the ECM program is voluntary, and individuals can decline to participate at any point. Regular reports on program enrollment, engagement and quality outcomes are produced and sent to provider partners. Inquiries about CMCS's ECM Program can be sent to Linda Grosser, Director of Quality, via email at: lgrosser@cmcs-indy.com. Expansion of Case Management Planned for 2016 Embedded case manager programs have shown to be effective in reducing re-admissions, closing gaps in care, reducing length of stay and improving quality of care.

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