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Prospective Care Management in Action

Prospective Care Management goes beyond traditional disease and care management.  Below are examples of how Prospective Care Management has improved the lives of our members. 

Member Challenges:

A 60-year-old male with mild mental retardation lives with his hearing impaired wife, adult son, and his son’s young family.  He suffers from many ailments, including COPD, diabetes, reflux and high cholesterol.  Because of his mental health challenges, he is illiterate when it comes to understanding the dynamics of his multiple conditions.  As a result, the member rarely has any follow up with his PCP after frequent hospitalizations.  To make matters worse, his house is not set up to receive the PA Relay TTY/TDD phone line for the hearing impaired, so the Care Manager (CM) could not communicate with the member’s wife.

Prospective Care Management solution:

The CM scheduled regular PCP visits in order to better manage his multiple conditions.  Both the CM and member held a conference call with Human ARC to apply for Supplemental Security Income (SSI), for which he was approved.  They are also working to get a TTY/TDD line set up in the home so the CM can communicate with the member’s wife.

Results:

Within a few weeks there were marked improvements with the member’s overall health.  The Prospective Care Management team made an appointment for the member to see an optometrist, and the member now has new prescription eye glasses.  The member has not required any ER visits or hospitalizations because his symptoms are better controlled.  CM also made a referral to Neighborhood Diabetes and, member is now for the first time, checking his blood sugar regularly.  Thanks to the novel Prospective Care Management approach, the member is now enjoying life by being able to do more for himself and for his family.

 

Member Challenges:

A 58-year-old woman with disabilities, who suffers from anxiety and depression, spent an extensive amount of time in various state mental hospitals and has been living on and off in community housing for the past 12 years.

She was eventually referred to Gateway’s Interdisciplinary Care (ICT) Team after she had numerous problems with her power chair and was having trouble getting follow-up from the durable medical equipment (DME) company.

Prospective Care Management solution:

Using the  Prospective Care Management approach, the Gateway Care Manager (CM) intervened and contacted the member’s church social worker.  The member was grateful for the opportunity to be heard by the care team, and for the opportunity to speak with a psychiatrist, as she has many fears stemming from her mental illness and experiences in the state hospital system.

Results: 

New parts have been ordered for her wheelchair so the issue is resolved.  The member reported that she had never had an insurance company pay so much attention to her previously and is so grateful.  She can now get around much better in her repaired wheelchair.  She is also much less anxious since being referred to a trusting psychiatrist.