Targeted Care Management (TCM) Program Description

Program Mission/Goals/Target Population:

A. Program Mission:

The mission of the Targeted Care Management Program is to promote a normalized adjustment in the community and to avoid the life style disruptions of repeat acute care admissions for those members with a history of multiple admissions.

B. Program Goals:

1. To increase community tenure for UMBH’s most at-risk members. 
2. Improve quality of life and levels of adaptive functioning of the target population.
3. Improve compliance with post-discharge treatment, as non-compliance is a major contributor to unsuccessful post discharge adjustment resulting in readmissions.
4. Provide a source of support, information, and education to members of the target population.

C. Target Population:

The target population is enrollees of all ages who have had two or more admissions in a 12-month (or shorter) period.  Re-admissions are monitored monthly and enrollees are added accordingly.

Program Management

The TCM Preventive Health Program is under the direction of the Medical Director who obtains assistance from faculty of the Department of Psychiatry and Behavioral Sciences. These Individuals provide consultation and guidance in their areas of expertise. The Director of Clinical Operations manages the day to day functioning of the program and supervises the Manager of the Program, who is a senior licensed clinical social worker.

Interventions and Frequency

All acute care admissions are staffed during daily rounds, which are attended by the Medical Director, MD Peer Reviewers, Acute Care Managers, Targeted Care Managers, and the Director of Clinical Operations. There is an emphasis on the early development and close coordination of the post discharge treatment plan prior to discharge. At the point of discharge the Targeted Care Managers are responsible for monitoring the implementation of the treatment plan. Member Services, Quality Improvement, Clinical Operations, and MIS staff provides administrative support. The Targeted Care Management Program coordinates with HMO’s medical-surgical care management nurses assigned to high-risk med-surgical cases.

1. Aggressive coordination of discharge treatment plan developed by facility/attending, UMBH Medical Director, Acute Care Managers, Targeted Care Managers, Outpatient Provider, the Member and significant others.
2. Ongoing reminder calls to members.
3. Verification of attendance for each visit as indication of compliance with treatment plan.
4. Targeted Care Managers coordinate a full array of community resources to improve adjustment in the community.
5. Diagnosis-specific provider profiling facilitates referring members to particular practitioners for optimal outcomes.
6. All members with evidence of treatment plan non-compliance are targeted for contact with the goals of early assessment of the reasons for non-compliance and removing of barriers to future compliance.
7. Use of multiple providers when indicated, including visiting nurses and injectable medications to improve compliance.
8. Second and third opinions are provided faculty of the Department of Psychiatry on complex or difficult-to-manage members.

Program Assessment and Outcome