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Case Management Overview | CMO Nurse Case Managers - Roles and Responsibilities
Clinical Care Guidelines and Protocols | Discharge Planning and Follow-Up
Ancillary Support Services and Home Visits | Readmission Rounds

Overview
Case Management involves the coordination of care across the healthcare delivery continuum for members with complex and/or chronic illnesses or conditions. Our services are designed to proactively anticipate the individual needs of a patient and to provide the scope of necessary health services to help return the member to optimum health. Our involvement spans hospital care, rehabilitation, outpatient care, professional services, home care, ancillary services, community-based services, remote patient monitoring and any other services. Throughout the process, we focus on helping patients to participate in establishing goals and individualized care plans.

The goals and objectives of CMO Case Management Services are to:

• Identify patients requiring coordination of services to improve healthcare outcomes and quality of life;
• Provide value to physicians and patients by facilitating care;
• Work collaboratively with members of the healthcare team involved in the care of members in case management to ensure the development of appropriate care plans; and
• Effectively advocate for the needs of members.

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CMO Nurse Case Managers - Roles and Responsibilities
CMO Nurse Case Managers are registered nurses with extensive clinical and case management experience. Working in teams that include Utilization Management Analysts who are non-clinician support staff, behavioral health professionals and physicians, these teams work collaboratively with the members' physicians to support the practitioners' care plan for the member. Case Management also involves active identification of members at risk for exacerbation of chronic illness and the application of interventions in a manner that has a positive effect on members' outcomes.

Working with physicians, members and often the member's family or caregiver, it is the role of CMO's highly qualified Nurse Case Managers to:

1. Conduct a thorough and systematic evaluation of the member's current status addressing the following components:
• Physical/functional status
• Clinical history
• Psychosocial
• Behavioral
• Environmental
• Family/caregiver support systems and availability
• Financial
• Learning capabilities/self-care


2. Assess resource utilization, diagnoses, and related past and present treatments and services, prognosis, goals (short/long term), treatment and provider options.


3. Reach out and collaborate with the member's practitioners to support the care plan.


4. Interview member/significant other(s) to research and gather relevant information to develop the plan of care.


5. Proactively identify situations that are, or may become, barriers to a member's achievement of goals.


6. Maintain professional collaboration and communication with the member/caregiver/family and other members of the healthcare team to the extent possible so that the plan of care can be discussed objectively, problems can be identified, and adjustments can be made to the plan as needed.


7. Proactively identify behavioral health issues, which may impact compliance with the medical plan of care, and refer the member to the behavioral health counterpart in accordance with the Medical Management/Behavioral Health Coordination of Care Policy.

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Clinical Care Guidelines and Protocols
CMO has extensive experience in the development of clinical guidelines and continually refines these guidelines by convening multidisciplinary teams of physicians, nurses, pharmacists, researchers and other clinicians with expertise in a particular medical condition. These teams review, discuss and modify nationally recognized guidelines.

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Discharge Planning and Follow-Up
CMO has developed a number of key initiatives to support the hospital discharge planning process, particularly for patients with post acute care needs. The purpose of discharge planning is to ensure that the patient's discharge plan is in place and to identify any unidentified needs as soon as possible after discharge and create an appropriate plan of care.

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Ancillary Support Services and Home Visits
CMO has established strong relationships with nursing homes, rehabilitation facilities, dialysis centers, home care agencies and other community-based agencies as well as being one of the first organizations in the nation to design and maintain a successful House Calls program.

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Readmission Rounds
Readmission rounds are designed to prevent avoidable readmissions of recently discharged members; to identify and provide interventions for members who are at risk for declining health status and subsequent readmission or costly outpatient services; and to ensure PCP collaboration in the plan of care.

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