Case Management FAQ

Q. What does a Community Health Plan of Washington Case Manager do?
A. A Case Manager at Community Health Plan of Washington (the Plan) works with members and providers to optimize the member's ability to access care, and to empower them to improve self-management of their condition. They provide education and serve as a member advocate. They facilitate discharge planning and the processing of authorization requests and they interpret benefits. They help members locate medical or community resources.

Case managers:

  • Work with the member's doctor(s).
  • Talk with the member's other providers.
  • Answer the member's questions.
  • Help the member access medical and community resources.

Q. Who is appropriate for case management?
A. Patients appropriate for case management include:

  • Patients with complex or chronic care needs.
  • Patients with complex discharge planning needs.
  • Patients with needs that are beyond the available clinic resources, such as:
  • A patient with a medically complex or fragile condition with comorbidities who needs help breaking down access barriers.
  • A child or adolescent patient admitted to a residential treatment center.
  • A transplant patient.
  • A patient who attempts suicide.

Q. How do I refer a patient to case management?
A. All lines of business can be referred to Case Management. Referrals can be sent via phone, email, letter, or fax. A completed referral form is preferred but not required.

Refer your patient by faxing the online form or by calling Case Management:

Q. What happens after I refer a member for case management?
A. All referred individuals are screened for case management services. Case Management attempts to contact the member via phone and mail. Members may decline case management services at any time.

When a member consents to Plan level Case Management, staff conduct a detailed case management assessment over the phone. With the member's input, Case Management creates an individualized care plan.

Ongoing member contact occurs monthly, or more frequently as needed.

Adult case management is assigned by region:

  • Region 1 — Central Urban Puget Sound (excludes all Sea Mar)
  • Region 2 — Northwest Washington (includes all Sea Mar)
  • Region 3 — Southwest Washington (includes all YVFWC locations)
  • Region 4 — Eastern Washington (excludes all YVFWC locations)

Specialized case management services are available for children (ages 0-13) and high-risk OB.

Click Names/Numbers on the Case Management web page to get a current list of Case Management contacts in each region.

Q. How will I know if a member is in case management?
A. When a member has been opened to Plan level Case Management, the PCP receives a notification letter and monthly care plans. When case management services are no longer needed, the PCP receives a case closure letter and final care plan.

Q. How will the PCP be kept informed of the member's status?
A. The member's assigned PCP receives individualized care plans that are updated monthly. Details include summaries of the member's current health status, ability to perform ADLs, self-management needs, mental health status including cognitive function, adequacy of caregiver resources, health care directives, available benefits, and cultural needs, preferences, or limitations.

Q. When do case management services end?
A. Services typically end when Case Management goals are met. Other reasons a member may be closed to case management include:

  • Termination of coverage with Community Health Plan.
  • Member declines further case management services.
  • Case Management is no longer able to contact the member either by phone or letter.

Q. What is Enrollees with Special Health Care Needs (ESHCN)?
A. This term refers to persons who have chronic and disabling conditions, including persons with special health care needs that meet all of the following conditions:

  • Have a biologic, psychological, or cognitive basis.
  • Have lasted or are virtually certain to last for at least one year.
  • Produce one or more of the following conditions stemming from a disease:
  • Significant limitation in areas of physical, cognitive, or emotional function.
  • Dependency on medical or assistive devices to minimize limitations of function or activities.

For children: the previous definition with any of the following conditions:

  • Significant limitation in social growth or developmental function.
  • Need for psychological, educational, medical, or related services over and above the usual for the child's age.
  • Special ongoing treatments such as medications, special diet, interventions, or accommodations at home or school.

Q. Who qualifies for the ESHCN program?
A. Only Healthy Options, CHIP, and Basic Health Plus enrollees qualify for this program. For the Healthy Options population, we are obligated by state contract to: Identify; Assess; Treat; Coordinate care; and Provide open access to specialists if needed.

Q. What happens after assessing an ESHCN member?
A. The member is opened to Plan-level Case Management or referred for Primary Care Case Management, unless the member opts out. When goals have been reached in Plan-level Case Management, the PCP may receive Primary Care Case Management notification during the transition of care.