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Gestión y coordinación de la atención médica de TotalCare (HMO D-SNP)

TotalCare care management focuses on identifying and addressing members’ medical, behavioral health, functional and social needs, coordinating across care teams and community resources to help members achieve their personal health goals.

Every TotalCare (HMO D-SNP) member is assigned a care manager when they enroll. A care manager is a licensed registered nurse or social worker. Care management is provided at no cost to the member.

Members can connect to a care manager by calling TotalCare Care Management at 800-700-3874, ext. 5512 (TTY: 800-735-2929 (Dial 711)), Monday–Friday, 8 a.m. to 5 p.m.

Members can opt out of these services at any time by telling their care manager.

The following TotalCare care management components are required:

Una Health Risk Assessment (HRA).
An Individualized Care Plan (ICP).
An Interdisciplinary Care Team (ICT).

Providers also play an important part in helping manage transitions of care (TOC).

More information about provider roles in these processes is detailed in the "Timelines and provider roles" section below.

Care coordination

Our TotalCare care management team partners with primary care providers, specialists, behavioral health providers, long-term services and supports (LTSS), and community organizations to:

Provide member-centered care coordination across all settings, using outreach, education and reminders to reduce missed opportunities for care.
Complete and update Health Risk Assessments (HRAs).
Develop and maintain Individualized Care Plans (ICPs) with specific, measurable, achievable, relevant and time-bound (SMART) goals.
Facilitate Interdisciplinary Care Teams (ICTs) with members and their chosen supports.
Stratify risks and target outreach based on member needs.
Connect members with community resources and social supports.
Provide support during transitions of care (hospitalization, skilled nursing facility or emergency department visits). Care managers help with information exchange, medication reconciliation, timely follow-ups, and identifying barriers to recovery such as transportation or medication access.
Identify and close gaps in care and quality measures. This includes preventive screenings, diabetic eye exams and A1c/CKD monitoring, statin therapy adherence, follow-up after hospitalization for mental illness and medication adherence for chronic conditions.

Risk stratification

Members are risk-stratified using clinical, functional and social criteria such as HRA responses, utilization, diagnoses, medications and social determinants of health. This process guides the intensity of care management outreach and ICT involvement.

Typical tiers include:

High Risk: Complex comorbidities or frequent hospital use; frequent contact and ICT involvement.
Moderate Risk: Stable chronic conditions with barriers; focused coordination and health coaching.
Low Risk: Preventive focus with outreach as needed.

Timelines and provider roles

Providers act as essential partners in the TotalCare care management process by:

Collaborating with the care management team and sharing timely updates.
Designating a point of contact for care coordination and after-hours communication.
Reviewing and validating HRA data, including medical, functional and social risk factors.
Collaborating to set SMART goals.
Participating in or providing input to ICT meetings and reviewing follow-up action items.
Updating the medical record promptly and sharing relevant care plan changes.
Respecting member preferences, language and accessibility needs, using interpreter services when appropriate.

The timelines below align with TotalCare’s Model of Care requirements.

Documentation	Frequency/Timeline	Provider Role
Health Risk Assessment (HRA)	Initial HRA must be completed within 90 days of D-SNP enrollment. Annual HRA must be completed at least once every 12 months or when there is a significant change in health status.	Respond to care manager outreach. Share relevant clinical information. Confirm recent services or admissions.
Individualized Care Plan (ICP)	Initial ICP: Developed within the same 90-day window as the HRA. Updates: Al menos annually or whenever the member experiences a major change in condition or goals.	Review ICP goals. Contribute to evidence-based interventions. Document the provider’s role in the care plan.
Interdisciplinary Care Team (ICT) (Participants include the member, their representative and key providers involved in the member’s care.)	Convened as needed and at least annually.	Attend ICT meetings (or provide input). Share updates. Coordinate interventions.
Transitions of Care (TOC)	Timely notification of admissions/discharges, medication reconciliation and post-discharge follow-up coordination.	Notify the plan of hospital admissions and discharges. Share discharge summaries promptly. Ensure the member has a timely follow-up visit.