Care Management

Care management

As part of our Population Health Management Strategy, Regence care management supports the unique needs of members with acute, chronic and major illness episodes or severe illness conditions. The mission of care management is to prioritize the needs of our members in their communities by providing personalized, equitable services that enhance their quality of wellbeing.

We offer a single-nurse model dedicated to delivering personalized and holistic medical and behavioral health support to each member and their family. Case managers are experienced registered nurses and social workers. Our case managers work closely with providers to help our members improve their health and meet the goals of their providers' treatment plans.

Care management goals include:

  • Advocating for members and their support systems
  • Improving care through close collaboration with providers
  • Supporting members transitioning to different levels of care
  • Assisting members as they navigate the health care system
  • Educating members about their care options, benefits and coverage
  • Ensuring full compliance with national quality standards, including those established by NCQA
  • Supplementing information given by providers to help members make educated decisions regarding their health care
  • Improving members' clinical, functional, emotional and psychosocial status by supporting their health and wellness needs, as well as their independence
  • Collaborating with behavioral health providers to meet the needs of patients with chronic illness or comorbid conditions, such as chemical dependency and depression

Also included within care management offerings for members with chronic conditions are:

  • Newsletter to all members with new diagnosis of depression, anxiety, painful condition or adult/pediatric cancer once per year with an option to opt into care management
  • Condition-specific newsletters to all members with diagnosis of coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma or diabetes twice per year with an option to opt into care management

Providers can contact our Care Management Intake Team to refer members to care management. Members can also self-refer to our program. In addition, we proactively identify and outreach to those members most likely to benefit from additional support, education and collaboration with providers.

Identification criteria includes members who:

  • Have a new diagnosis of diabetes, myocardial infarction (MI), congestive heart failure (CHF), multiple sclerosis (MS), rheumatoid arthritis (RA), hemophilia, dementia, cystic fibrosis, leukemia, brain cancer or muscular dystrophy
  • Have an established condition when new to our health plan with diagnoses of chronic kidney disease (CKD), end-stage renal disease (ESRD), hemophilia, history of transplant or complications from transplant
  • Have extended inpatient stays >8 days
  • Have post-discharge in long lengths of stay greater than five days
  • Are readmitted in less than 30 days or any three admissions in 12 months
  • Are receiving transplants (identified during pre-authorization, pre-transplant)
  • Have high medical claim costs and/or are taking medications that incur high costs
  • Are living with a serious illness, serious advanced illness or end-of-life diagnosis (palliative)
  • Have high emergency room (ER) utilization of three or more ER visits in six months or "super user" of more than 10 ER visits in 12 months

Once a member is identified, the designated case manager calls the member. We attempt at least three calls before sending a letter to the member. The member can respond to the letter if they wish to engage with a case manager. Providers are sent a letter or contacted by phone when their patient is enrolled in care management.

Regence Condition Manager

Regence Condition Manager is our educational program delivered through Optum for administrative services only (ASO) groups, available as a buy-up. The program is delivered over the phone to members who could benefit from direct support and education to manage a specific health-related condition, including:

  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure (CHF)
  • Coronary artery disease (CAD)
  • Diabetes

Members identified as low-risk* receive:

  • Program welcome letter
  • Access to 24/7 nurse line
  • Option to work with a case manager
  • Bi-annual disease management newsletter
  • Monthly review of claims data for re-stratification
  • Disease management brochure with invitation to work with a case manager
  • Invitation to work with a dedicated case manager (even though the members are not high risk)

*The low-risk program also includes "education-only" members (members originally identified as high-risk but who have not responded to outreach—neither opted-in nor out).

High-risk members receive:

  • All low-risk interventions
  • Condition-specific educational guide
  • Ongoing case manager education and support
  • Comprehensive condition-specific assessment
  • Member notifications when gaps in care are identified
  • Depression assessment (managed as a co-morbidity)
  • An individualized care plan in collaboration with provider

Contact our Care Management team