Provider Education on Complex Case Management
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Read More InfoAbrazo Advantage Health Plan (AAHP) offers members the opportunity to participate in the Case Management Program when they become overwhelmed by multiple health problems.
AAHP’s complex case management program for SNP members is known as chronic care management due to the multiple needs of the members. Care management refers to the collaborative effort among physicians, members and AAHP which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet member needs. The care manager works with the member, their family or significant other, the PCP and other providers who offer care to the member to make sure they get the care they need and prevent exacerbation of illness. A care plan will be developed especially for the member and will include input from the member, their family or significant other, PCP and other providers. The care plan includes:
- Long and short-term goals, barriers to meeting goals, communication with member and assessment of progress against plan
- Assessment of health status, mental status, including cognitive functions, ADL, life planning activities
- Evaluation of cultural & linguistic needs, care giver resources and available benefits
- Self-management plan (if indicated)
AAHP also offers a diabetes and asthma disease management program which focuses on each disease.
You may refer members to the program or they may refer themselves. The member has the right to opt out of the program.
The provider can use this service to monitor the member’s self-management of the condition, preventive health issues, relevant medical test results and mental health issues. It is also a source for managing member comorbidities, lifestyle issues and medication management.
Our goal is to join with providers, community services, and family members to achieve optimal outcomes. If you would like to refer a member to the Care Management program or need additional information please contact Case Management at 602-824-3700.