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Our care management model promotes prevention skills, performs health risk identification, and manages member compliance to avoid costly treatments. We not only outreach to the sickest members to stabilize and manage conditions, we guide healthy members further along the prevention path. Through our five main service areas of Preventive Health, Transition of Care, Complex Care, Maternal/Child Health and Behavioral Health, we catch members wherever they are on the health continuum.
To refer a patient for Care Management services, call 800-557-6916, Monday through Friday, 8 a.m. to 5 p.m. You can also email firstname.lastname@example.org.
Services are provided to members showing a potential risk, an anticipated risk, or a known risk, with the intent to prevent that risk from becoming a significant care need. Support includes health and wellness promotion such as exercise, nutrition and screenings, but these services are also designed to stabilize a member’s health to prevent it from worsening. Qualified health care professionals will provide assistance to help close gaps in care, which may include: annual wellness visits, screenings, monitoring labs to ensure therapeutic levels of a medication, earlier intervention, and engagement with a health care provider to proactively manage a potential health exacerbation based on clinical indicators (i.e. elevated blood pressure and HbA1c that are not within range). Services include:
- Health maintenance and prevention reminders to promote self-management skills
- Health Education
- Recommendations on how to manage and maintain overall health and wellness
Complex care management provides care management services for members with one or more complex medical conditions and over or under utilization of health care services. JHHC recognizes that individuals often have two or more health problems that can be well served by evidenced-based care management.
We provide service to adults with asthma, diabetes, cardiovascular conditions, chronic obstructive pulmonary disease, sickle cell, cancer, pain management, Alzheimer's, rehabilitative needs, HIV/AIDS, seizure disorders, developmental disabilities, chronic kidney disease and chronic lung disease. We provide services to children 18 years and younger with chronic conditions such as asthma, diabetes, sickle cell disease, neurological devastation, various genetic syndromes, cancer and morbid obesity, or after an organ transplant.
- Complex Care Management Assessment completed on all members
- Coordinate transitions of care that do not fit within the Transitional Care Services model
- Coordinate care with PCPs, specialists, DME/service providers
- Support self-management
- Address barriers and gaps in care by creating innovative solutions and involving community resources
- Education on signs and symptoms of worsening disease
- Identify appropriate level of care
Transition of Care
Provided following a health event, such as a recent hospitalization, the diagnosis of an illness, a life-changing event such as a birth, or a decision to receive long-term care services). Designed to assist members and their loved ones with coordinating a set of clinical resources and navigating the complexities of the health care system.
- Coordination of durable medical equipment and supplies
- Medication management and reconciliation
- Appointments with providers (existing and newly identified)
- Understanding diagnosis
- Establish a relationship with providers
Partners with Mom is a maternity care management program that targets all pregnant women. High-risk moms with a history or current symptoms of asthma, diabetes, pre-term labor, substance abuse, hypertension, and/or adolescent pregnancy are followed by our OB nurse care manager. Pregnant mothers with other high-risk OB diagnoses that may benefit from care management interventions are also considered for inclusion into this program. Pregnant women with no risk factors receive ongoing assessments during the pregnancy to identify any potential risks.
If a baby needs care in the NICU, our care managers work with the parents to ensure their understanding of their baby’s care. We also assist the parents in their transition home.
Through early identification and intervention, the program has reduced antepartum admissions, decreased NICU births, and improved maternal/fetal outcomes. Partners with Mom care managers are available for onsite, high-risk clinic sessions to provide the critical resources and services needed. Care managers work closely with the provider and member to improve compliance, coordinate care, and maximize favorable outcomes.
This care management service area will also serve high-risk and at-risk pediatric members from birth through age 18.
For members living with a mental health condition such as depression, autism spectrum disorder, anxiety or addiction, we provide care management services, which may include access to confidential care coordination support.
These clinicians use a unique team approach to assist you through your treatment needs. Services include coordination with all providers, treatment resources, and health coaching.
Behavioral health services can be obtained by calling 800-557-6919, Monday – Friday, 8 a.m. – 5 p.m.
JHHC's health programs and services are voluntary and are provided at no cost to the member. Members identified with certain needs may be automatically enrolled but are under no obligation to participate.