Case Management Services

Complex case management

MedStar Family Choice provides Complex Case Management Services for adult and pediatric members who require an extensive use of resources or assistance coordinating complex care. This service is provided telephonically by Registered Nurse Case Managers who work to ensure that members receive appropriate and timely medical services. Member eligibility for Complex Case Management is based on diagnosis and medical services that meet the following criteria:

• ≥1 inpatient admission in 6 months

• ≥2 Emergency Department visits in 6 months

• Special needs populations (as defined by COMAR) who are not otherwise covered in MedStar Family Choice Comprehensive Case Management Services

• Complex psycho-social or behavioral needs

• A critical event or diagnosis such as/not limited to Sickle Cell Disease with Severe Crisis, Liver Failure, Cancer/Tumors, Stroke, Transplants, or Acute Trauma with complex care coordination needs

Services offered to MedStar Family Choice members participating in Complex Case Management Services include:

• Support from our Case Managers and other staff to ensure that your patients receive the assistance they need to facilitate appropriate services

• Educational materials, as appropriate, to understand their conditions

• Assistance in coordinating homecare services as needed for skilled care, as well as any outstanding teaching needs

• Information on community or MedStar Health events, such as health fairs or support groups that may be pertinent to their conditions

Comprehensive case management services

Comprehensive case management services are available to MedStar Family Choice adult and pediatric members with certain medical conditions. Registered Nurse Case Managers or Social Workers offer telephonic support and education to empower your patient with self-care strategies. Coordination of care and education is provided. The following list includes criteria, but is not limited to those eligible for comprehensive case management services:

• High-Risk Pregnancy

• Diabetes

• Asthma

• COPD

• Hypertension

• Cardiovascular Disease

• HIV

• Substance Use Disorder

• Social Issues/Mental Health

Transition care case management services

Transition Care Case Management is a service provided by MedStar Family Choice to assist your patient if they were just discharged from the hospital. This service is provided by Registered Nurse Case Managers who work closely with your patient to assist with following the discharge plan order by the hospital care team, locating providers, and scheduling follow-up appointments. This service is offered for 30 days, and if after that time your patient requires further assistance, they will be referred to one of our other case management services.

Rare and expensive case management (rem) services

Members of MedStar Family Choice do not have to enroll in our Complex Case Management, Comprehensive Case Management, Transition Care, or REM services. They are automatically included in the programs when they are identified as meeting qualifying criteria. Membership in all services is voluntary and members have the option to stop participating at any time. A copy of the information provided to members can be obtained by contacting the MedStar Family Choice Case Management department.