URAC

Care Management

Care Management services include:

  • Utilization management
  • Prospective review
  • Concurrent review
  • Retrospective review
  • Case Management

The HDP Care Management department utilizes a primary nurse model. The UM Registered Nurse is responsible for pre-certification services, continuing through concurrent review and discharge planning for any case she initiates. The same Registered Nurse provides all services, helping members navigate an increasingly complex system and preventing gaps or overlaps in care. The UM nurse is responsible for the management of all aspects of a hospital case, including the early initiation of discharging planning and arrangement of any post hospital service needs such as Home Health Care, Durable Medical Equipment, Skilled Nursing Care, and / or Rehabilitation.

The UM nurse is also responsible for referral to CM, and Disease Management (DM) or Maternity Management (MM). All of these services are housed within the Care Management Department. There is a “warm transfer” of cases from UM to CM, DM and / or MM nurses as appropriate.

HDP CM is a collaborative process that includes any disciplines, resources and/or contacts that could help improve a member’s quality of life. The service is meant to coordinate, monitor and evaluate options for members with complex health care needs to promote quality, cost-effective care. CM opportunities are identified in a variety of ways, including UM, claims data, and provider, family or patient referral and through application of a consistent set of screening criteria. The program is voluntary and involves goals set jointly by the case manager, patient and/or family member and provider. A CM nurse is assigned to work with specific clients so that she has a thorough knowledge and understanding of the client’s population and plan benefits. She will remain primary on a case until goals are met and discharge is achieved to ensure continuity of care.

The HDP Medical Director, a practicing physician board certified in internal medicine, is integral to Care Management at HDP. The Medical Director provides clinical guidance for and oversight of all Care Management programs. In addition, the Medical Director functions as the Chair of the Medical Dental Advisory Committee, a group of 20 clinical specialists available for consultation and case reviews. The Medical Director also co-chairs the Clinical Quality Committee and participates in appeal determinations.

HDP strives to be “user friendly” to every caller who contacts the Care Management department. HDP accepts information from the member, physician or facility.

The Care Management department can be reached by phone or fax 24 hours per day. Callers outside of normal business hours are directed to leave information in a confidential voice mail box; calls are returned the next business day.

HDP sends satisfaction surveys to a large sample of members and providers who have used UM services and to all members completing CM programs. Results indicate a 99% satisfaction rate.

HDP provides all utilization management (UM) and case management (CM) services in house. HDP employs an all Registered Nurse staff, with many certified case managers. Nurses have extensive clinical experience and many years of managed care experience. Care Management staff members have backgrounds in:

  • Cardiology
  • Critical Care
  • Geriatrics
  • Diabetes Management
  • Maternity
  • Nutrition
  • Oncology
  • Orthopedics
  • Pediatrics
  • Psychiatry
  • Women’s Health

Milliman USA Care Guidelines®

HDP uses the Milliman USA Care Guidelines®, which is a clinical criteria set that spans the continuum of patient care in a variety of care settings. In addition to Care Guidelines, the nursing staff has access to a board-certified medical director and a committee of local medical advisors who provide clinical guidance to all aspects of the Utilization Management and Case Management programs.