Complex Care Management

Complex Care Management

The Care Management program focuses on both prevention as well as high quality integrated care delivery for members who have been diagnosed with chronic conditions. Services are intended to improve patient outcomes and reduce the instances of unnecessary or expensive medical care for patients with 2 or more chronic conditions.

Specialized nurses, dietitians, clinical pharmacists, and other behavioral therapists collaborate with members, their physicians, and other healthcare professionals. Our team is able to facilitate access to healthcare services and provide resources including education for health-related decisions; ensuring members obtain the highest quality of care, maximize their healthcare coverage, and save money.

Avance Care’s approach includes personalized, high touch, nurse-centered care coordination to engage patients in their own wellness efforts on decrease unhealthy days associated with chronic disease progression.

Initial Services Include:

  • Comprehensive initial assessment with care manager
  • Coordination of care with all healthcare providers by retrieving and merging medical records in a standard format for ongoing care management
  • Comprehensive review of all medications with ongoing medication therapy management with a clinical pharmacist, if needed

Ongoing Services Include:

  • Identification of gaps and barriers to care Development of individualized plan of care with steps for achieving a member’s goals
  • Assistance with scheduling appointments for follow-up care, including labs and specialists
  • Consultation with dietitian or behavioral therapists, if needed

Who is Eligible for This Service?

Any member with two or more chronic conditions is eligible. Example conditions include diabetes,
hypertension, cancer, COPD, cardiac conditions (CHF, cardiomyopathy, CAD), asthma, arthritis, renal
failure, etc.