Outpatient Case Management

Program description:

Kaiser Permanente’s outpatient Case Management program coordinates the care and services of Kaiser Permanente of Washington’s members with multiple chronic conditions and complicated medical/social needs often resulting in the extensive use of resources. The program is designed to comply with the standards set forth the by the National Committee on Quality Assurance (NCQA) and is integral to the accreditation for the health plan.

Kaiser Permanente of Washington’s outpatient Case Management program promotes the member’s health and wellness goals through patient centric education. Through coaching techniques, we educate the member on the principles and value of self-management and help build a climate of collaboration between themselves and their care team.

Standards of practice

Case management involves the timely coordination of quality services to address a client’s specific needs cost-effectively and safely to promote optimal outcomes. This can occur in a single health care setting or during the client’s transitions of care throughout the care continuum.

The professional case manager serves as an essential facilitator among the client, family, or caregiver, the interprofessional health care team, the payer, and the community.

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes. (CMSA)

Eligibility:

For a member to be eligible to participate in one of the programs listed below, they must have current Kaiser Permanente coverage and agree to actively participate in the program they select and meet the qualification criteria defined in the program and services section below.

Staffing:

The case manager is a licensed and certified professional currently certified through one or more of the following nationally recognized organizations: Commission for Case Managers Certification, American Case Management Association, Certified Managed Care Nurse, or American Nurse Case Management Certification.

Programs and services:

Chronic Condition Case Management (CCCM):
Provides complex case management services to specific patients identified with one or more of the following high-acuity chronic conditions:

• Cardiology
• Nephrology
• Neurology

Complex Case Management (CCM):
Provides complex case management services to specific patients identified with one or more of the following conditions:

• Asthma
• COPD
• Coronary artery disease
• Diabetes
• Heart failure
• Hypertension
• Pediatrics
• High-cost patients
• High utilization of services

Transitional care:
Ensures high readmission risk patients discharging from an inpatient setting have the necessary outpatient treatment components in place for a safe successful transition back home supporting follow through with the agreed upon discharge plan.

• Coordination of care
• Resource connection
• Member/family education
• Member advocacy

Post hospital discharge phone calls:
Patients are encouraged to contact the Care Management Self-Referral Line at 1-866-656-4183.
Physicians’ referrals can be made through Health Connect referral order entry process or Kaiser Permanente Customer Service.

Program goals:
In addition to the standard case management goals, the CCM program works to achieve the following goals:

• 60% or greater of members are discharged as having met goals
• Member program satisfaction is equal to or greater than 90%