Harvard Pilgrim provides case management services to help patients attain optimum health and quality of life and achieve greater self-reliance in managing their health care. Our complex case managers are nurses who provide systematic coordination and assessment of services using evidence-based clinical guidelines. Harvard Pilgrim’s complex case managers partner with our staff social workers and pharmacists and draw on disease management programs (such as asthma, diabetes, etc.) to help coordinate care and access to services for patients with multiple complex conditions.
These programs assist patients with conditions such as chronic kidney disease, cancer, heart disease, and a variety of rare diseases. Complex case managers help patients avert the need for more intensive medical services by providing them with information tailored to their needs and stage of readiness. Our case management programs focus on diagnostic conditions and proactively identify at-risk patients. Typically, the patients in our case management programs have co-morbidities and psychosocial needs that can significantly diminish their quality of life and make it difficult for them to adhere to treatment plans.
Case management programs are available to members identified through:
- Algorithms based on medical, pharmacy, and/or radiology claim analysis
- Hospital discharge data
- Provider and case manager referral
- Self referral
- Health risk appraisal
For more information about Harvard Pilgrim’s complex case management programs, including how to refer patients, please see the Complex Case Management page on Harvard Pilgrim’s website or call 866-750-2068. Also, if you have patients interested in Harvard Pilgrim’s complex case management programs, they can get more information on the program by visiting the diseases and conditions section of our member Health and Wellness page.