Complex Care Coordination

Nurse smiling with doctor in the background

CareFirst’s complex care coordination is targeted to medically unstable members who typically have more than one chronic condition with complex care coordination needs. Employees identified for this support through an HTC referral or from a review of their health care use are at a high risk of breakdown in health status, ER visits and hospital admissions/readmissions. Complex care coordination is critical to improve their outcomes. The goal is to stabilize members in the home setting to prevent hospitalization and readmissions, ER visits, and consequences of dangerous drug interactions.

This program 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 as well as additional resources to support the member. Care coordinators assist the PCP in coordinating all elements of the member's health care and developing individual care plans, which outline the member’s medical needs with specific follow-up activities to better manage or improve their health.

Because adhering to care plan goals is fundamental to improved health outcomes, CareFirst has strategically designed incentives that require members’ full compliance with them. One such incentive, our cost-share waiver, is specifically intended to improve outcomes, reduce hospital admissions and increase compliance with care plans, by removing a key barrier to care—the cost. As long as a member is actively involved in and compliant with their care plan, in-network cost-sharing (copays, coinsurance, deductible) is waived for non-hospital, professional claims.