For members with complex diagnoses or special needs, we offer a variety of health services to help them manage their condition on a daily basis.
These health services are recommended for patients for whom Case Management may reduce the risk of adverse outcomes, those who have complex medical or behavioral health conditions or high psychosocial risk factors.
Care management, case management, and health coaching are available at no additional cost. Patients can self refer to these services or their physician can refer them using the Case Management Referral Form.
More information about each service is provided below.
Care Management is part of the Medical Management Department. We work with providing clinic to create a care plan that promotes the wellness of the member. This team consists of clinical and nonclinical staff in each of the following areas, all with the goal of ensuring an actionable care plan for members:
- Case Management
- Health Coaching Program
- Community Linkages
Case management is a collaborative process that addresses the individuals health needs of our members. It involves the coordination of services to identify alternative options and educate members about resources available to them. A case manager’s role is advocacy, assessment, and coordination of care between multiple providers and the member. Members must be referred to the case management program.
Our health coaching programs identify patients with chronic diagnoses such as diabetes, asthma, and/or chronic pulmonary disease (COPD), and engages them to see if they need extra help. The goal of health coaching is to improve the member’s quality of life by helping them stick to an actionable care plan.
Health Risk Assessment
Patients with chronic diagnoses or special needs will fill out a Health Risk Assessment prior to starting a health coaching or care management program. For access to a patient’s HRA, please contact their case manager.
Special Needs Plan: Transitions of Care
Community Health Plan of Washington is committed to managing the transition of all SNP members from one care setting to the next, and back to their medical homes. This process will necessitate activities for us and the attending caretaker(s) at each service facility. Please review and familiarize yourself with the following minimal expectations required to be completed whenever there is an SNP member planned or unplanned inpatient or discharge event.
They include but are not limited to:
- A discharge summary
- Medication list review with the member
- Review of any required follow-on appointments
If you have questions regarding Community HealthFirst Medicare Advantage Plans or Policies, please contact your Provider Relations Representative.