South Atlantic Medical Group’s Case Management department consists of RNs, LVNs, social workers and other allied health workers. The dedicated case management staff are assigned to members with chronic conditions or other needs that require one or more of the following services:

• Facilitating conference calls between the member, the physician and the case manager as needed to clarify treatment plans, medication regimens or other urgent issues
• Assessing the member’s daily living activities and cognitive, behavioral and social support
• Connecting members and their families with professionals who can help them address medical, legal, housing, insurance and financial issues facing older adults
• Assisting members in obtaining home health and durable medical equipment
• Monitoring medication adherence
• Assessing the member’s risk for falls and providing all-prevention education
• Helping caregivers access support and respite care
• Arranging access to transportation
• Referring members to meal-delivery programs and advance directive preparation services

The Case Management Program works in collaborative coordination with all members of the health care team. This involvement includes the patient and family, primary care physician, specialty providers and the Provider Network leadership, and Case Managers in the decision-making process in order to minimize fragmentation of the healthcare delivery system.

The Case Management Program is developed as a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs. This purpose is affected through communication and use of available resources to promote quality and cost-effective outcomes. The Case Management Program is developed to specifically address the needs of the member with high cost, high volume, and high-risk health care experiences, allowing the member to take control of his/her healthcare needs.

The Case Management Program identifies the client by diagnostic/ symptomatic categorization at initiation points of service, with a focus of early identification of risk factors and a needs assessment. The goal is to identify and intervene early to affect the best outcome for the catastrophically impacted, chronically ill, injured, or high-risk OB members.

Disease Management is a set of activities aimed at improving the health and clinical outcome of a population of members with a chronic medical condition. The Disease Management Program utilizes a system of coordinated healthcare interventions and communications for populations with conditions in which member self-care is significant. The Program is designed to assist members with chronic health conditions to be their healthiest. Members of the program receive case management and learn how to manage their conditions and how to minimize hospitalization and chronic complications. Knowledge sharing, coaching and community social support are integral to this program.

The Disease Management Program identifies its members by ancillary data, utilization or claim data, hospital and medication history, and through health risk assessments and provider referrals. The goal is to effectively help members set specific goals in order for them to achieve optimum health.

The goals of case management are to:

• Provide appropriate access to care.
• Integrate and improve the coordination of care by ensuring optimal health status, providing social or community support systems, promoting a safe environment, reducing the impact of
  behavioral health issues, and encouraging self-reliance.

The goals of disease management are to:

• Help members regain optimum health or to improve their capabilities and patient safety.
• Minimize or avoid hospitalization and complications and reduce excessive healthcare costs and resources.

South Atlantic Medical Group’s. supports standards of performance include:

• Appropriate, timely, and beneficial service which promotes quality and cost- effective health care outcomes.
• Professional licensure, training and knowledge of health and social services.
• Collaborative, proactive, and patient-focused relationships.
• Adherence with applicable state and federal laws.
• Ethical practice principles with respect for dignity, privacy and rights of the individual.
• Advocacy for the member and the family, including awareness to culturally appropriate care.