Care Management and Coordination

Care coordination from one main point of contact!

A care manager is a licensed Registered Nurse or Social Worker who provides you with care coordination services, especially during care transitions and hospital discharges. Your care manager can work with you and your care team to create an Individualized Care Plan (ICP).

When you enroll in TotalCare (HMO D-SNP), you will be assigned a care manager who can help you:

• Understand your health plan benefits.
• Find doctors and specialists within the network.
• Coordinate your health care (doctor visits, home health, behavioral health, therapy and more).
• Choose or change a provider.
• Get authorizations for care, equipment or supplies.
• Transition health care like when you leave the hospital.
• Get Long-Term Services and Supports (LTSS) and help from community resources.
• Arrange transportation to and from your medical appointments.
• Schedule health screenings.

Care Team
A care team consists of you, your primary care provider (PCP), your care manager and any other individual that supports your health. This may include family members, friends or other health professionals that you choose to include. A care team is led by your case manager and works with you to create your care plan.

Care Plan
A care plan tells you and your doctors what services you need and how you will get them. Your care plan will be made just for you and your unique needs. This includes your medical, behavioral health and LTSS needs.

Your care team will work with you to create a care plan.

Your care plan will include:

• Your personalized healthcare goals.
• A timeline for when you should get the services you need.

Your care team meets with you after your Health Risk Assessment (HRA) has been completed. They will talk to you about the services you need and about services you may want to get. Your care team will work with you to update your care plan at least yearly.

Members or their doctors, family members, caregivers, or hospital discharge planners may request care management and care coordination services. To make a request, call TotalCare Care Management at 800-700-3874, ext. 5512 (TTY: 800-735-2929 (Dial 711)), Monday - Friday, 8 a.m. to 5 p.m.

When a care manager is assigned to you, you will get a phone number to call them directly. Learn more about Care Management.

When you first join the TotalCare plan, you will be asked to complete a Health Risk Assessment (HRA). An HRA is a tool that helps your doctor learn more about your current health conditions and how your daily habits affect your health. This information helps your doctor understand how you're doing physically and mentally and find ways to help you stay healthy, feel your best, and help your care team manage your care.

The HRA is also used to develop your Individualized Care Plan (ICP). The HRA will have questions to identify benefits or services that you may need such as LTSS, behavioral health and functional needs. The HRA helps to identify actual and potential changes so that your care manager can help you access community and health resources.

We will call you to make sure you complete the assessment if you didn’t complete one when you enrolled.

If you need help with completing your HRA, call TotalCare Care Management at 800-700-3874, ext. 5512 (TTY: 800-735-2929 (Dial 711)), Monday through Friday, 8 a.m. to 5 p.m.

CICM offers extra support for members with complex health needs. CICM helps you manage your care, coordinate with your providers, and connect to local services that support your health and daily life.

Community Supports (CS) can help you with housing, getting food after a hospital discharge, hospital discharge support and more. Learn more on our Community Supports page.

If your current primary or specialty care provider isn’t part of the TotalCare network, you might still be able to see them for a certain amount of time. This is called continuity of care. Learn more on our Find a Provider page.

If you are currently receiving services from an Enhanced Care Management (ECM) provider, call Member Services to check about staying connected and ask for continuity of care. You can continue receiving services from an ECM provider for up to 12 months. Contact Member Services at 833-530-9015; (Hearing and Speech Assistance - 800-735-2929 (TTY: 711)) to request “Continuity of Care.”

Long-term Services and Supports (LTSS) are for people who need help with everyday tasks like bathing, using the bathroom, getting dressed, making food and taking medicine. Most of these services are provided at your home or in your community but could be provided in a nursing home or hospital. In some cases, a county or other agency may oversee these services and your care coordinator or care team will work with that agency.

Most LTSS help you stay in your home so you don’t have to go to a nursing home or hospital.

LTSS includes the following:

• Community-Based Adult Services (CBAS)
  • Health and social services provided at a licensed, community-based health center.
  • Learn more about CBAS.
• Nursing Facility (NF)
  • A facility that provides care for people who cannot safely live at home and does not need to be in the hospital.
• In-Home Supportive Services (IHSS)
  • The IHSS Program may help pay for services provided to you so that you can remain safely in your own home if you qualify.

Your care manager can help you understand each program. To find out more about any of these programs, contact TotalCare Care Management at 800-700-3874, ext. 5512 (TTY: 800-735-2929 (Dial 711)), Monday through Friday, 8 a.m. to 5 p.m.