Case Management Program

What is the Case Management Program?

The Case Management program is voluntary and confidential designed for members of FHC of Puerto Rico, Inc. (FHC) who receive mental health services. Our approach to the Case Management Program (CMP) is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality and cost effective outcomes.

What is the goal of the program?

The goal is to increase the adaptive capacities and the level of functionality of the members, offering self-help tools to work their recovery process at the least restrictive level of care and improve their and their family’s quality of life.

To achieve this goal, the following strategies will be used

  1. Perform initial evaluation.
  2. Educate members about their rights and responsibilities, the process of complaints and grievances, and the right to opt-out case management services.
  3. Assist the member to develop the member-centered care plan.
  4. Keep the member informed about the different service options that are available for recovery.
  5. Facilitate the implementation of the member-centered care plan.
  6. Maintain communication with the health care providers about the member’s health history, level of functioning, services that are being rendered and member-centered care plan.
  7. Establish formal liaisons with community resources such as support groups, agencies and programs.
  8. Provide helpful coordination of services after discharge from hospitalizations.
  9. Assist the member to access services he/she needs in the community.
  10. Assist the member to function in the roles he/she has selected. The CM includes family members and community resources for these interventions.
  11. Serve as an advocate for the member to get quality services of medical, vocational, educational and recreational type.
  12. Assist the member to develop skills to successfully function in his/her natural environment, home, work, family and community.
  13. Ensure the continuity of the member-centered care plan by providing follow up calls, communication with providers and others involved in his/her recovery.
  14. Offer psychoeducation modules to help the member and the family into developing self-management skills for daily living activities.
  15. Visit member at home as necessary, in order to provide support and follow up with the goals of the member-centered care plan, with the integration of the family and significant other, as appropriate.

How do you enter the program?

FHC has multiple avenues for members to be considered for the CMP, including:

  1. Primary Care Physician referral.
  2. Discharge planner referral.
  3. Member or caregiver referral.
  4. Practitioner referral
  5. Self-referal

The referral process begins with the completion of the referral form, as well as, with any other type of verbal or written communication to request an evaluation for admission to the CMP. It is the responsibility of the Case Manager (CM) or Supervisor to evaluate the referral and determine if the individual meets the admission criteria. The referrals are accepted from the following sources:

  1. Disease Management: Disease Management staff from  the health plans are informed of the possibility of referring to the CMP via FHC’s providers newsletter, sent to all providers, which directs providers to FHC’s website for information about referring to CMP (Press here).
  2. Discharge planners: Discharge planners can refer members to the CMP through the following link in the FHC web page (Press here), or through theprocess during their frequent contacts with FHC’s clinical staff.
  3. Mental health professionals: Mental health professionals are informed about their ability to refer through the following link on the FHC website (Press here). The professionals are informed through the educational activities offered to the providers by FHC. The mental health provider can also contact FHC by telephone to make the referral.
    1. MCS Classicare: 1- 800-760-5691
    2. MCS Life: 1-866-627-4327
    3. Triple S Federal: 1-800-660-4896
    4. Municipio de Guaynabo: 1-866-808-4614
  4. Utilization Management (UM) at FHC: If at the timeof the utilization review process to determine medical necessity for a pre-service, concurrent or retrospective reviews, a member is determined to be potentially appropriate for CMP, the initial  reviewer completes the referral to the program through the different types of communication, including the FHC website (Press here).
  5. Members:Members are informed of their ability to self-refer to CMP thru the information posted on FHC’s website (Press here). Members also  can contacts FHC by telephone to self-referral :
    1. MCS Classicare: 1- 800-760-5691
    2. MCS Life: 1-866-627-4327
    3. Triple S Federal: 1-800-660-4896
    4. Municipio de Guaynabo: 1-866-808-4614
  6. Caregivers:The caregivers can refer their family members to the CMP through the following link in the FHC’s website (Press here). The caregiver or family member can contacts FHC by telephone to complete the referral:
    1. MCS Classicare: 1- 800-760-5691
    2. MCS Life: 1-866-627-4327
    3. Triple S Federal: 1-800-660-4896
    4. Municipio de Guaynabo: 1-866-808-4614
  7. Practitioners:Practitioners are informed of their ability to refer a member to CMP by information posted on FHC’s website (Press here).  Practitioners are informed annually via providers newsletters sent to all practitioners that information about CMP’s referring process.  To refer, the practitioners can contact FHC by telephone:
    1. MCS Classicare: 1-800-760-5691
    2. MCS Life: 1-866-627-4327
    3. Triple S Federal: 1-800-660-4896
    4. Municipio de Guaynabo: 1-866-808-4614

 

What can I expect from the case manager (CM)?

The case manager offers the member:

  • A professional service that guarantees confidentiality, in accordance with Law 408 and the Health Insurance Portability and Accountability Act (HIPAA).
  • Work with the member to achieve an optimal level of functioning in the least restrictive treatment.
  • The opportunity to contact public agencies that help the member work with their social stressors.
  • An individual and personalized management.
  • Link between the member and their mental and physical health providers to guarantee quality services.

Does this program replace the member’s treatment?

No, the program is designed to support mental and physical health treatment services.

What is expected from the member and his family?

They are expected to make a commitment, not only to the program, but also to their recovery and treatment process, complying with the recommendations offered by both, their health providers and the case manager.