Case Management and TriWest
Case management takes a collaborative, integrated approach to managing the complex health care needs of an eligible beneficiary. The
case management programs include medical/surgical and behavioral health case management, as well as specialty programs, such as Cancer
Clinical Trials, TRICARE ECHO program, transplants, and hospice.
Case management is a process designed to assess, plan, implement, coordinate, monitor, and evaluate the options and services necessary
to meet an individual’s health care needs. Using communication and available resources to promote quality, cost-effective outcomes,
case managers work one-on-one with the providers.
TriWest case managers act as beneficiary advocates, working with multidisciplinary teams utilizing clinical skills and knowledge to
help ensure the best possible care is provided.
Beneficiaries who have complex, catastrophic health care needs may benefit from the case management program. The beneficiary, a family
member, or a provider can make referrals to case management by contacting TriWest. A military treatment facility (MTF) or a member of
TriWest’s staff can also refer beneficiaries to case management. When a beneficiary is in case management, his or her case manager
may provide multiple services, including:
-
Identifying and facilitating needed services and equipment, and promoting the beneficiary’s self care in collaboration with the
PCM for optimal health care delivery and in conjunction with the MTF and Veterans Affairs (VA) resources
- Decreasing the provider’s administrative tasks by assisting with referrals and authorizations and locating specialty providers
- Educating the beneficiary on TRICARE benefits and systems
- Identifying community resources
-
Educating the beneficiary on his or her disease process and promoting lifestyle changes that can positively affect the management of
the disease (
e.g., compliance with the recommended treatment plan, adherence to medication regimen, and keeping scheduled physician
appointments
)
-
Providing a point of contact to assist with problem solving, acting as a beneficiary advocate, and assisting in communicating with caregivers
on behalf of the beneficiary
The following are examples of conditions for case management:
- Acute HIV/AIDS
-
Burns (3rd degree or extensive 2nd degree)
- Cardiovascular conditions
- Head trauma
- Neoplasms and malignancy
- Neurological conditions involving intensive care or unconsciousness for more than 48 hours
- Obstetrical conditions that require hospitalization prior to delivery
- Expected multiple birth
- Admissions to a neonatal intensive care unit
- Previous history of intensive care for an infant
- Respiratory failure with new ventilator dependence post hospitalization
- Spinal cord injuries
- Severely injured active duty service members
- Behavioral health admissions of children 12 years old and younger
- Life-threatening suicide attempt
- Two inpatient behavioral health admissions within 90 days
- All psychiatric residential treatment center admissions for adolescents
- Transplant – organs, bone marrow or stem cell
- ECHO registration
- Candidate for National Institute (NCI) Phase II or III Cancer Clinical Trials
- Hospice Care
Please go to the Forms area of
www.triwest.com/provider for more
information on the program criteria and instructions on how to refer a beneficiary to case management. Under
Clinical Programs,
select the
Case Management Patient Referral Form.
Published Date:
12/18/2008
