Ch 18: Case Management

Case Management Program

VHP’s case management (CM) program is designed to help providers manage their VHP members and to assist members in obtaining needed services from community resources. These resources include covered and non-covered services when determined to be medically appropriate for the needs of the member. VHP’s CM team manages care for members whose needs are functional and social as well as those with complex medical and/or behavioral conditions. For pregnant members, pre-natal care, perinatal mood disorders and maternal mental health are areas where CM can assist members in receiving the appropriate, supportive care and services. Children with special health care needs may be at higher risk and are also appropriate for VHP’s CM program. VHP uses a holistic approach by integrating referral and access to community resources, transportation, follow-up care, medication review, specialty care, and health education. Case managers partner with providers to help the member achieve their selfmanagement health care goals.

All VHP members are eligible for comprehensive CM programs, including complex CM, condition-specific CM, and autism spectrum disorder (ASD) CM. Members who have been identified with chronic complex, acute complex, high-risk conditions, or gaps in care, regardless of condition, generally benefit from intensive one-on-one advocacy care, care coordination, and education provided through CM programs.

Health Risk Assessment Screening

VHP offers health risk assessment (HRA) screening to all Commercial Employer Group, CoCA and IFP members. HRA screening is voluntary, free of charge, and confidential. Information gathered includes current and past medical conditions, psychosocial network and support systems, barriers to health care, gaps in care, and self-care ability. The results are used in two ways: cumulative and individual. At the cumulative level, the information is used by VHP for program development. At the individual level, the information is used to identify members for case management programs and other quality initiatives

Case Management Team

The CM team includes a Medical Director, Registered Nurses, Licensed Clinical Social Workers, Medical Social Workers, Care Coordinators and Community Outreach Specialists. The member’s designated case manager conducts a comprehensive assessment of the member’s medical, behavioral, and psychosocial needs through the administration of a health risk assessment (HRA) which supports the identification of barriers to care or well-being. The case manager is also responsible for the development and implementation of an individualized care plan as well as coordination of care among the member’s caregivers and providers to achieve good quality of care outcomes. Below Is a more detailed description of case management at VHP:

Complex Case Management:

• Case management for the highest risk or highest cost members; or • Members with multiple, ongoing physical, behavioral and social concerns.

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Condition Case Management:

• Focuses on improving the health of members with chronic conditions through enrollment in specific programs such as biometric monitoring for members with class II and IV heart failure; • Supports the treatment plan established by the provider through education and health coaching; and • Provides care coordination to address the member’s needs.

ASD Case Management:

• Provides access to resources for members with ASD diagnoses who are under 21 years of age; • Provides support and addresses barriers for families caring for special needs children; and • Partners with the primary care providers and coordinates care across multiple specialty areas.

How to Contact VHP’s Case Management Team

A CM team member is available to help providers manage their VHP members. You may initiate a real-time referral via email at vhpcasemgmt@vhp.sccgov.org, through fax at 1.408.947.4251 or Epic/HealthLink if you are part of the County of Santa Clara Health System by using the VHP Case Management Referrals email portal (see below).

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Entities Delegated for Case Management

If an independent practice association (IPA), medical group, or other organized provider entity has been delegated responsibility for Case Management, refer to Chapter 22, “Delegated Entities.” Conformance with VHP’s policies, procedures, protocols, protocols, VHP’s Provider Manual and all applicable regulatory and accrediting standards is required.

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CH 19: Behavioral Health Services

This Chapter Includes:

1. Provider Expectations: Integrating Physical and Behavioral Care 2. Communication with the Primary Care Providers 3. Outpatient Behavioral Health Services and Authorization

Requirements

4. Inpatient Behavioral Health Services and Authorization

Requirements

5. MDLIVE Telehealth Benefit

6. Applied Behavior Analysis 7. Eligibility Requirements 8. Initial and Continuation of ABA Services Requirements 9. Behavioral Treatment Plan Requirements 10.ABA Services Provided by Registered Behavior Technician

(Paraprofessionals) Requirement

11. Supervision Guidelines 12.Documentation Requirements 13.BHT Code Submission

Alert

Alert draws attention to critical information that has changed this year.

Contact

Contact information on who to contact for assistance.

Book Table of Contents

Click the purple VHP circle logo, located at the bottom left corner, to return to the main TOC.

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