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Special Needs Resources

Integrated health care management/complex case management

The Integrated Health Care Management (IHCM) program, which includes complex case management, provides comprehensive case management and disease management services to our highest-risk members. The program coordinates resources for members who are expected to experience future adverse events, and assists members who have medical, behavioral, and/or social issues that affect their quality of life and health outcomes.

Identified issues and diagnoses that would be referred to the program include:

  • Multiple diagnoses (three or more major diagnoses).
  • Pediatric members requiring assistance with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services.
  • Pediatric members requiring in-home nursing services.
  • Members with dual medical and behavioral health needs.
  • Members with behavioral health diagnoses needing assistance with referral to a behavioral health managed care organization (BH-MCO) or special help with accessing medical care.
  • Members with intellectual disabilities.
  • Members with elevated blood lead levels (EBLL 5 mcg and above).
  • Members with chronic diseases, including:
    • Heart failure.
    • Diabetes.
    • Asthma.
    • Chronic obstructive pulmonary disease (COPD).
    • Coronary artery disease.
    • Sickle cell anemia. 
    • HIV/AIDS.
    • Hemophilia.

We provide service through telephonic outreach, assessment, and intervention. The staff makes outreach calls to the member and/or member representative, as indicated, and collaborates with the primary care practitioner (PCP) and specialist to develop a treatment plan.

Contact Integrated Health Care Management: 1-877-693-8271, option 2

Special Needs Unit

This unit coordinates services for new adult and pediatric members and for existing members who have short-term and/or intermittent needs, single-problem issues, and/or multiple comorbidities.

Case Managers help resolve pharmacy, durable medical equipment (DME), and/or dental access issues; assist with transportation; identify and provide access to specialists; and provide referrals and coordinate with behavioral health providers or other community resources. There is also a dedicated Case Manager who liaises with BH-MCOs for members with both physical and behavioral/mental health issues, and collaborates with government offices, health care providers, and public entities for members with special needs.

Contact the Special Needs Unit: 1-800-684-5503

Bright Start® program for pregnant members

With a focus on improving prenatal care for pregnant members, this program assesses, plans, implements, teaches, coordinates, monitors, and evaluates options and services required to meet individual health needs. The program fosters collaboration between the Case Manager, member, obstetrician, and BH-MCO for assessment and interventions to support the management of behavioral and social health issues.

The program’s goals are to:

  • Identify pregnant members (using a variety of sources including Obstetrical Needs Assessment Forms [ONAFs]; Logical Observation Identifiers, Names and Codes [LOINC]; and pharmacy data) and obtain accurate contact information.
  • Improve health outcomes for neonates.
  • Facilitate access to services and resources:
    • Dental screenings.
    • Behavioral health screenings.
  • Build relationships with community-based agencies that specialize in services for maternal/child health.
  • Encourage prenatal and postpartum care by increasing awareness through member newsletters, media engagements, provider education, and community alliances.
  • Assess and address health care disparities in pregnant women.

Members receive interventions depending on the assessed risk of their pregnancies. Case Managers play a hands-on role in coordinating and facilitating care with members’ physicians and home health care agencies. Case Managers also provide outreach to ensure member follow-up with medical appointments, identify potential barriers to getting care, and encourage appropriate prenatal behavior.

Using informatics reports and assessment information provided by the obstetrics practitioner, members are triaged into low-risk and high-risk populations: 

  • Low-risk members receive educational material about pregnancy and delivery, and how to access a Case Manager for any questions or issues.
  • Low-risk members receive an outreach call after delivery to complete a postpartum survey.
  • High-risk members receive “high touch” case management interventions from a Case Manager.

Contact the Bright Start program: 1-877-364-6797

Let Us Know program

The Let Us Know program is a partnership between AmeriHealth Caritas Pennsylvania and the provider community to collaborate in member engagement and management. We have support teams and tools to assist in member identification, outreach, and education, and also clinical resources for providers.

Contact Integrated Health Care Management by faxing the Member Intervention Request Form to 1-866-208-8145. Use this form to request interventions such as:

  • Noncompliance with prescribed medications.
  • Not showing up for appointments or follow-up care.
  • Inappropriate use of the emergency room.