ü Compassionate, cost-saving programs that ensure
high-quality health care
ü Consistently high member satisfaction ratings for our
case managers
ü Disease management programs
that focus on the member, not the disease
ü Pregnancy support including a 24-hour pregnancy line
ü 24-hour Nurse Line
From preventive health programs for healthy people, to
disease management for members with chronic diseases, to the compassionate
services of case management, we have continuously enhanced our care management
systems to meet customer needs and manage the cost of health care. We work
closely with members and their families and physicians, and with health care
facilities, to ensure that members receive appropriate, high-quality,
cost-effective care.
Blue Care
ConnectionSM is an integrated approach to health care management that spans the
spectrum of health: from wellness to chronic disease to catastrophic illness.
BCBSNM offers important information, programs, and tools to help members be as
healthy as they can get!
§ Utilization
Management (UM) is a key component of
managed care that ensures patients receive the most appropriate and cost-effective
care using preauthorization, concurrent review, discharge planning, outpatient
service/procedures review, pharmacy utilization management, and retrospective
review.
§ Case
Management
- Case management is another of the important health
care services we provide to our members. Our case managers are registered nurses
certified in case management who work closely with the patient and family, treatment
teams in acute care facilities, rehabilitation facilities, and skilled nursing
facilities to coordinate and assist in developing the best treatment plan for
the member.
- The case manager is an advocate and facilitator whose goal
is to reduce fragmentation of care for each member. The Case Management Program
is voluntary and participation in the program does not alter the member’s
benefit plan.
§ Disease
Management
Our disease management program focuses on members who
have a chronic disease for which coordination of care and the optimal use of
self-care improves their health status. We have programs for diabetes, asthma, coronary
artery disease including hypertension, congestive
heart failure, chronic obstructive pulmonary disease,
low back pain, and prenatal/pregnancy care. BCBSNM participates in state
initiatives to support improved health care opportunities for our members.
Outcomes and improvements are routinely measured using national measures and
goals.
§ Prenatal
Programs
- The Special Beginnings® Prenatal Program is available to
all our members whose plans include maternity benefits and is designed to
provide additional support and education during pregnancy. The program includes
confidential pregnancy/health questionnaires, educational material, a 24-hour
nurse line, and case management for high-risk pregnancies.
- The My Healthy Pregnancy Program was
developed exclusively for BCBSNM/HMONM members by Mayo Clinic Health
Information and is available to all our members (the relationship between
BCBSNM and Mayo Clinic is solely that of independent contractors). This program
offers online tools and information designed to help members understand and
manage their pregnancy. Features include e-mails on lifestyle issues and articles
on baby’s development and the changes that moms-to-be experience.
§ 24-hour
Nurse Line
We
offer the 24/7 Nurseline for our members. The goals of the Nurseline are to
improve the member’s ability to make health care decisions, improve the
patient-provider relationship, reduce avoidable health care utilization, and
provide an audio library. The nurse encourages member call backs to confirm
understanding, and will make follow-up calls to verify outcomes. The audio
library contains over 1,200 health care topics, with over 500 also available in
Spanish.
§ Wellness/Preventive
Care programs provide information
from national resources, centers of excellence, and local services to inform
and educate members on how to maintain and improve their health. We provide general
health-related information, specific information available on request, and
targeted information based on the member’s age and sex. Communications are
delivered by print, phone, electronically, and through classroom instruction, incorporating
member and provider education and capitalizing on the services of local
providers.
We
provide benefits for wellness and preventive services, including immunizations,
mammograms, and cholesterol testing. Members and providers receive annually
updated preventive health guidelines. BCBSNM mails reminder cards to parents to
help them keep on track with their children’s immunizations and birthday cards
to women reminding them to schedule a mammogram and Pap test. We participate in
state health and wellness initiatives and collaborate with other plans to
achieve common goals. We measure outcomes using national methodology and set
goals according to state, regional, and national measures.