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Care Management

Care management programs we offer help address members who are:

  • Seriously ill or have complex conditions
  • Managing a chronic condition
  • At risk for developing serious or chronic illnesses
  • Recently hospitalized and could benefit from after care or transitions in care support
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How we identify members

We identify members based on multiple sources, including medical and pharmacy claims, and other self-reported information.

What we do

Interventions are designed to help members avoid illness, boost wellness, enhance quality outcomes, and decrease health care costs by addressing gaps in care and medication management in accordance with their clinician’s or physician’s treatment plan. These interventions may include:

  • Educational and informational materials to help members understand and manage their medications, make appropriate lifestyle choices, and find additional resources for support
  • Ways to plan for effective doctor visits
  • Preventive screening and lab reminders
  • Review of medications to address any potential safety issues, adherence, or other reminders
  • Reviewing social determinants of health, such as food insecurity and financial issues, and offering support to help address those needs
  • Case management and navigation support after a hospitalization

Some members receive additional nurse coaching by phone. We reach out to treating providers if there are specific concerns raised that you may need to be aware of.

How we impact our members

Here are some real-life stories of how our care management programs have helped our members.

Blue Cross member Michael Grimm
Newly diagnosed with diabetes
“I left the hospital uneducated, uninformed and scared that I wouldn’t be able to live a life with diabetes.”

–Michael Grimm, Blue Cross member

New Year’s Day 2018, Michael Grimm didn’t understand what was happening. The 29-year-old triathlete and Augusta, Ga., resident was hospitalized for fatigue and unexplained weight loss after he dropped 25 pounds in five weeks. He was barely able to stand upright.

When the doctor told Grimm he had type 1 diabetes, he was shocked.

He needed answers and information.

A few days after he was discharged, Grimm was surprised to get a call from Blue Cross Nurse Case Manager Milly Hawke.

Hawke, a registered nurse who is certified in diabetes education, regularly follows up with members like Grimm to ensure they understand their diagnosis and how best to manage their condition after discharge from the hospital.

Grimm would later say taking that first call was the best decision he had made since falling ill.

Read the full story

Blue Cross members Jim and Ann Bunyan
Helping navigate through a sudden, serious illness
“Honestly, I don’t know how I would have gotten through this without her [Blue Cross nurse case manager Donna Buonopane-Johnson].”

- Ann Bunyan, Blue Cross member

During the hardest times, help can sometimes come from a simple phone call.

Read the full story of the support the Bunyan family received.
How to make a referral

We welcome provider and member referrals. If you think a member could benefit from care management, please complete our Patient Referral for Health Management Programs & Services Form and return it to the fax number indicated. Or, call Health Management Programs at 1-800-392-0098, Option 1.

For questions about Federal Employee Program member referrals, please call 1-800-689-7219, Option 2.

For members with this plan Call
HMO, PPO, Indemnity Case Management
1-800-392-0098, Option 1
Federal Employee Program (FEP) FEP Case Management
1-800-689-7219, Option 2
Medicare Advantage Case Management
1-800-392-0098, Option 1
Medex Case Management
1-800-392-0098, Option 3
Other programs (administered by vendors)

REACH (Recovery, Education, and Access to Community Health)
This program is offered at no cost to our members, through our partnership with Beacon Health Strategies. REACH is designed to help patients with behavioral health difficulties and/or substance use disorder by arranging care with health care providers to ensure patients feel supported when they leave the hospital. Learn more about REACH.

Landmark Health
For our Medicare Advantage members with multiple chronic conditions, we offer Landmark Health. Landmark’s providers—physicians, nurse practitioners, and physician assistants—go to patients’ homes of patients to help keep them well, and provide urgent care when needed. This service does not replace the care provided by the member’s PCP.

An independent company that manages diabetes care for some of our members in self-insured accounts.

This is a medication therapy management program for our Medicare Advantage members. This independent company works with our Medicare Advantage pharmacy benefit manager.

For members in self-insured accounts, we offer this program through Express Scripts, Inc., the independent company that administers our pharmacy benefits.

The program sends doctor and pharmacist alerts about medication safety, coordination of care opportunities, and possible gaps in care. These alerts are sent to doctors through their electronic medical records, by mail, or by fax.