Care Coordination

CareFirst has developed a support system of integrated programs and services to address the quality of care and cost issues challenging the health care system today. These programs and services offer a range of care coordination from hospital transitions to complex case management—all with the goal of reducing hospital admissions and readmissions.

Concierge Approach to Patient Care

Our programs encourage and promote an ongoing relationship between the member and their primary care provider (PCP)—physician or nurse practitioner—with the support of a team of nurses that help navigate the complexities of the health care system.

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Of all the transitions of care that occur, the most significant is from hospital to home. Readmissions are probable and generally unplanned. Among patients with the most common procedures in U.S. hospitals, as many as one in five were readmitted within 30 days*.

To address this, CareFirst employs a team of Hospital Transition of Care (HTC) nurses who monitor all hospital admissions across the United States. The goal is to quickly assess every admission—in real time, as it occurs—and decide which ones will likely require follow-up attention post discharge.

Nurses monitor all CareFirst admissions, anywhere in the country, and are onsite in the hospitals where more than 70% of CareFirst admissions occur.

By monitoring admissions, HTC nurses are able to identify patients who are at high risk for readmission, outreach to them while they are still in the hospital, and coordinate outpatient care after discharge.

* Agency for Healthcare Research and Quality, Statistical Brief #154.

Complex specialty care provides case management services for your most critically ill employees. Traditionally, case management is provided by a generalist who oversees care for patients without regard to their specific disease or illness. By contrast, CareFirst’s case managers are all registered nurses with considerable clinical experience in very specific specialties.

Case management services most often follow a hospitalization. The Hospital Transition of Care program is typically the entry point into case management prior to discharge. All specialty case managers are registered nurses with substantial experience in their respective specialties.

Nearly 1 in 2 adults live with at least one chronic disease and more than 75% of health care costs are associated with chronic conditions.* Without a comprehensive approach, expensive hospitalizations and complications are the standard for this population.

Employees identified for this support are at a high risk of breakdown in health status, ER visits and hospital admissions/readmissions. Care coordination is critical to improve their outcomes. The goal is to stabilize patients in the home setting to prevent hospitalization and readmissions, ER visits, and consequences of dangerous drug interactions.

Our chronic care coordination is carried out by a team of registered nurse care coordinators. The majority of these nurses live within the sub-region to which they are assigned and have considerable knowledge of the physician community. Care coordinators assist the primary care provider in coordinating all elements of the patient's health care and developing individual care plans. Care coordinators also ensure all action steps in the plan are followed up and carried out.

* Source: Centers for Disease Control and Prevention

Every day millions of Americans are affected by mental health conditions. In a given year, one in five adults experience mental illness and these issues are just as prevalent with children.*

Through their CareFirst benefits, members have access to a network of behavioral health providers who are able to assist with a variety of conditions such as anxiety, depression, eating disorders, substance abuse issues and more. As part of Total Care and Cost Improvement (TCCI), CareFirst provides behavioral health care coordinators who work closely with members to:

  • create a personalized action plan
  • understand and comply with treatment
  • examine lifestyle choices which may be affecting their condition
  • schedule appointments
  • locate additional resources
  • identify warning signs of relapse

As we continuously review our member population to identify those who would benefit from additional support, your employees may be proactively contacted by a CareFirst behavioral health care coordinator. CareFirst members may also self-refer into this care coordination program by calling 800-972-0716 or by visiting

* Source: National Alliance on Mental Illness

The FirstHelp health care advice line is our 24-hour, 7 days a week nurse help line. FirstHelp is staffed by registered nurses who can answer your employees’ general health care questions and help guide them to the most appropriate care.

How FirstHelp works:

  • Employee calls 800-535-9700 to speak with a registered nurse and explains symptoms (information provided is completely confidential)
  • Using clinical expertise and advanced information research systems, the nurse helps the employee decide on the best source of care such as self-care, their PCP or emergency care if appropriate

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