Care (Disease) Management
Criteria
Do you have a member who may need extra help managing their care? Care Management is a benefit provided by Mercy Care. The Care Management program is different than the ALTCS program. In Care Management, the acute member remains in the program until their goals are met or the member decides to opt-out of care management.
Care managers are professional nurses or social workers experienced in creating care plans that help members meet their goals.
A Care manager is usually assigned for a short time period to help members learn how to manage their illnesses and meet their health care needs. Because all members do not need Care Management, Mercy Care has developed criteria to determine who may benefit the most. If you feel a member may be appropriate for Care Management, review the following criteria:
- Does the member frequently use the ER instead of visiting your office for ongoing issues?
- Has the member recently had multiple hospitalizations?
- Is the member having difficulty obtaining medical benefits ordered by providers?
- Has the member been diagnosed with CHF, diabetes, asthma or COPD, yet does not comply with the recommended treatment regimen?
- Does the member need help applying for Arizona Long Term Care Services?
- Does the member have HIV?
- Is the member pregnant with high-risk conditions?
- Is the member a pregnant teen?
- Is the member pregnant and over 35 years of age?
- Has the member received a referral to a specialist, but is unsure of the next steps?
If one of your members has depression, high blood pressure, diabetes, asthma or congestive heart disease, please contact us so we can help them properly manage their disease.
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How do I make referrals for care (disease) management consideration?
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- For members who have Mercy Care without Medicare: AcuteCMReferral@mercycareaz.org
- For members who are pregnant, an email using the perinatal referral form can also be sent to: OBfaxes@aetna.com
- For members who have Mercy Care Advantage: MCACMReferral@mercycareaz.org
- For integrated RBHA members: AcuteCMReferral@mercycareaz.org
- For members with addictions to habit-forming substances, our Exclusive Prescriber Program can help. Send an email using the Exclusive Prescriber Program Referral Form to: MCP-PharmLock2@AETNA.com
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What happens to your referral?
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After you make a member referral, a registered nurse at Mercy Care will review the case and determine whether to assign a case manager or, depending on the need, refer the member to a different department for assistance. Since we are unable to care manage every member, we use predictive modeling software to help determine care management need.
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What will the care manager do?
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A care manager will contact the member to schedule a time to complete an assessment. They will ask the member questions about his or her health and the resources they currently use. Answers to these questions provide the care manager with a better understanding of what assistance is needed most.
Next, the member and the care manager will work together to develop a care plan. The care manager will also educate the member on how to obtain the care he or she needs. The care manager may also talk with the member’s health care providers to coordinate care needs. Once care plan goals are met, Mercy Care releases the member from the Care Management program.
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Additional resources through Community Information and Referral Services (CIRS)
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To assist a member with finding a place to live, getting food or other community resources not covered by Mercy Care, please contact Community Information & Referral Services at: 602-263-8856 or 1-800-352-3792 or go to CIRS.