Case management/Disease management

The Mercy Care RBHA Care Management program is designed to improve member health outcomes. The program provides needed care in the most appropriate setting and in a culturally competent and accessible format.

The Care Management program’s primary goals are to:

  • Identify the top tier of high-risk/high-cost members with serious mental illness who would benefit from an intensive level of care management in a fully integrated health care program
  • Provide care management to members who require care coordination
  • Effectively transition members from one level of care to another
  • Streamline, monitor and adjust members‘ care plans based on progress and outcomes
  • Reduce hospital admissions and unnecessary emergency department and crisis service use
  • Ensure members have the proper tools to self-manage care in order to safely live work and integrate into the community

Members who may benefit from intensive care management:

  • Members who require Special Assistance according to the Division of Behavioral Health Services Office of Human Rights and Mercy Care RBHA provider manual, section 5.4
  • Members with poorly managed chronic comorbid conditions
  • Members who frequently use the ER instead of visiting your office for ongoing issues
  • Members who have recent multiple hospitalizations
  • Members who have HIV
  • Pregnant members
  • Members who have multiple transitions of care

What will a care manager do?
The care manager will complete a comprehensive Case Analysis Review (CAR) that will include:

  • A medical chart review to identify member current health status, current providers service utilization, specific gaps in care
  • Consultation with the member’s treatment team
  • Review of administrative data, including claims and encounter data
  • Demographic and customer service data
  • Root cause analysis as to over- or under-utilization of services
  • Medication review, including updating a member medication list
  • Placement review, including updating a member placement history

The information from the CAR is used in the development of a member-centric plan of care that is streamlined and supports the member’s physical and behavioral health, social and community service needs, and placement goals, preferences and barriers.

How to refer a member to care management:
Call the care management referral line: 602-798-2627

Click on the link below to email the Care Manager Department Care Manager Department

Disease Management

Our Disease Management programs help members stay healthy. Members learn about their diseases and how to stay well by working their provider. Our program includes regular communications, targeted outreach and support, and focused education.

The conditions in our program include diabetes, asthma, chronic obstructive pulmonary disorder and congestive heart failure among others.

If you want to know more about our Disease Management programs, you can call 1-866-642-1579 or hearing impaired TTY/TDD 602-659-1144. Representatives are available 6 a.m. to 8 p.m.