Intensive Case Management: Health Education and Management Program

Keystone Mercy Health Plan is pleased to provide information about the member health education and management program: Intensive Case Management. This proactive medical care coordination program focuses on Keystone Mercy members with specific health risks.

Provider Case Management and Care Coordination Rights and Responsibilities

Providers who are treating members/consumers that participate in the Case Management/Care Coordination program have the right to:

Obtain information about Keystone Mercy including its programs and services, its staff and its staff qualifications
Be informed of how Keystone Mercy coordinates its interventions and plan of care for individual members
Know how to contact the CM who is responsible for managing the case, and communicating with the practitioner’s patients
Be supported by Keystone Mercy and work collaboratively in decision making with members/consumers regarding their health care
Receive courteous and respectful treatment from Keystone Mercy staff, and communicate complaints to Keystone Mercy

Providers are responsible to participate in the program through:

Providing relevant clinical information, as requested
Taking action to follow-up on reported information
Participating in the member/consumer plan of care

Based upon the illness and the severity of illness of your members, you may be contacted to refer Keystone Mercy patients to us for participation in one or more of the Intensive Case Management programs. These programs are intended to be a collaborative arrangement between our Case Managers and your existing treatment plans for the involved members and will in no way impede on your autonomy to provide care to members enrolled in the following programs.

Pediatric Preventive Care

This program provides the following services for members under 2 years of age:

Outreach calls for age appropriate EPSDT services
Outreach calls by Case Managers to members with children under age 1 who have no history of immunizations
Annual birthday card reminders for all EPSDT services
Identification of children with elevated lead levels to ensure ongoing care is received
Coordination of specialty care referrals and services for children with serious medical needs

All other EPSDT members (age 2-20) are eligible for all other EPSDT related services, including annual birthday card reminders for all EPSDT services due. For more information, please contact our Pediatric Preventive Care Liaison at 1-800-521-6007.

WeeCare Program (Pregnancy Management)

This pregnancy management program is called WeeCare and separates pregnant Keystone Mercy members into low and high intensity risk categories with the following goals:

Low Risk Pregnancy Management: Members will receive pregnancy-related educational materials encouraging good prenatal care.
High Risk Pregnancy Management: Pregnant members identified at risk for preterm labor and/or other pregnancy complications will be assigned a nurse case manager to provide ongoing supervision and education about pregnancy. A letter will be sent to the member's physician to notify him/her of the member's enrollment in the program with a summary of the initial assessment

All pregnant Keystone Mercy members have access to a 24-hour toll free Nurse Call Line at 866-431-1514. For more information or to refer members to our pregnancy management program please call 1-800-521-6007.

Special Needs Case Management

This program addresses the needs of members who self-identify or who have special medical requirements or risk factors that are identified through physicians, case managers, etc. Special Needs Case Management is not disease specific. For more information or to refer your patients with special needs call 1-800-521-6007.

Intensive Case Management

Intensive Case Management is a voluntary program focused on prevention, education, lifestyle choices and adherence to treatment plans. Intensive Case Management is designed to support your plan of care for patients with the following diseases:

Asthma

COPD

Diabetes

Members will receive educational materials and, if identified as high risk, will be assigned to a Care Manager for one-on-one education and follow-up. For more information or to refer a patient to our Intensive Case Management Program, call 1-800-521-6007.

Keystone Mercy also provides disease management services to members with the following diagnosis:

Sickle Cell

Hemophilia

Members in this program are assigned to a Care Manager who provides education and assistance with obtaining medications and specialty referrals. For more information or to refer a member to the HIV, sickle cell or hemophilia programs, call 1-800-521-6007.

The Intensive Case Management is also designed for Keystone Mercy members with multiple chronic illnesses who require complex case management for coordination of all aspects of care and services. Members will be assigned to a care manager that will assist in coordinating all aspects of care such as ensuring access to appointments and resolving transportation, pharmacy and equipment issues. The care manager will make scheduled telephone calls to ensure the member is following the plan of care. For more information or to refer a member to the Intensive Case Management program, call 1-800-521-6007.

Keystone Mercy is enthusiastic about the potential for positive health outcomes resulting from this new focus on prevention, education, and adherence to treatment plans. With your identification of members and consequent referrals to the programs listed above we can assure Keystone Mercy members are receiving appropriate levels of care.

All Keystone Mercy members have access to a 24-hour toll free Nurse Call Line at 866-431-1514. For more information or to refer members to our case management programs please call 1-800-521-6007.