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Medical management servicesThe Medical Management team is commited to service and support that exceeds the industry standard. The team views itself as a partner working with the employer and employees to understand and appropriately manage their benefits. Certification for inpatient admissions/outpatient proceduresThe Medical Management team screens and authorizes inpatient admissions and outpatient procedures. This ensures that the patient's condition/treatment warrants the service, the individual is an eligible member, the planned services are eligible, and the most appropriate setting is used for the service. Options such as home health care and outpatient services are utilized whenever medically appropriate. Ambulatory referral managementIf a member's benefit plan is designed as a gatekeeper model, the team will screen and authorize specialist referrals. Concurrent reviewThe team performs concurrent review on certified inpatient admissions and as necessary for outpatient services. This process verifies and documents the continued need for hospitalization or outpatient services and ensures our prompt awareness of any potential need for post-discharge alternative care services. When possible, the concurrent review process is accomplished on site. Outcome Facilitation Teams (OFTs) do this in Aurora hospitals in the Milwaukee metro area. The OFTs implement and monitor best practice, care pathways and Care Management initiatives, and apply InterQual ISD and M&R guidelines where appropriate to ensure timely and appropriate utilization of services. The teams consist of the primary RN, social worker, patient care manager, clinical nurse specialist, and other disciplines as pertinent to the patient's case including the community-based case manager, catastrophic case manager and managed care specialist, if necessary. Physicians may be contacted on a periodic basis to obtain additional information. Periodic treatment plan updates are necessary to assess the discharge planning needs of the member and to facilitate activities that meet these needs. Catastrophic case managementNurse catastrophic case managers plan, organize and sequence activities with the patient, family and care providers along the continuum of care to improve the outcome of catastrophic illness or trauma. The process positively impacts the cost of care through the effective and efficient use of the place of service, intensity of the treatment and duration of services. Community-based case managementCommunity-based nurses and social work case managers are assigned to physicians with patients who have been identified as high risk. The case managers develop a care coordination plan with their physicians. These managers ensure that high-risk patients are following through with physician recommendations and provide support where needed. Chiropractic reviewIn the event that a health plan doesn't include limits on chiropractic services, the Medical Management team screens and authorizes chiropractic services. This includes ensuring that the patients' condition/treatment warrant the service, that the patient is an eligible member, that the planned service is covered and that the most appropriate setting is being utilized. Plan design consultative supportThe Medical Management team works with the employer to advise and provide support regarding plan design. This service is based on extensive experience with various plans and current knowledge of medical standards of care. This also ensures that there is alignment between what is recommended for disease management services and coverage under the health plan. TeleservicesThe Aurora Teleservices unit provides advanced telephone-based patient risk assessment and management, and physician referral. This program enhances member health education and assists them with selecting appropriate health services. It also provides early identification of serious conditions to avoid costs of delayed or inappropriate care. Aurora Call Center is a demand management center that is also used by preventive services, wellness management, case management and care management programs to make outbound calls. Cost savings examples can be provided. Registered Nurses are available 24 hours a day at the Aurora Call Center. They have an average of 19 years experience. These RNs accurately identify needs and levels of urgency among callers. The RNs also have access to a translation line that allows them to assist members regardless of their primary language. If desired, members can receive printed information regarding their particular question or issue. This information explains in layman's terms what the particular illness is, how it occurs, how it is diagnosed, how it is treated, how long the effects will last and how the member can administer self care. This documentation serves to reinforce the verbal information given by the RNs. Aurora can also supply wallet cards and refrigerator magnets, as well as documentation on the use of the Call Center. For more information on Aurora Teleservices, click here. Clinical preventive care recommendationsAurora Health Care developed this set of clinical prevention recommendations for primary care providers. The recommendations are based on the guidelines developed by the U.S. Preventive Services Task Force and are intended for healthy low-risk patients. These guidelines are implemented for an employer's plan, and payment differentials can be implemented to encourage provider use of these recommendations. These guidelines serve as evidence-based recommendations regarding the appropriateness and frequency of various screening and preventive services for individuals and populations. They are proven interventions to decrease the rate at which healthy members become sick. Aggregate information about member compliance with the preventive care guidelines can be analyzed and made available to primary care physicians, members and employers. Health risk assessmentThe purpose of the health risk assessment is to identify and quantify health issues contributing to the risk that healthy individuals or groups will become sick. These programs provide consultation and education to groups and individuals as necessary for the risk areas identified. Aurora recommends that all members be assessed for health risks. Members will provide information through a standardized, confidential questionnaire. Aurora will then analyze the information and provide members with the opportunity for consultation and education. For more information on Aurora's Total Health risk assessment program, click here. Occupational healthOccupational Health services include treatment and management of work place injury and illness, wellness and prevention programs, rehabilitation, and exams and screenings required by federal and state regulations. It is a comprehensive approach to reducing unnecessary health and safety costs. It offers three types of services:
For more information on Aurora's Occupational Health services, click here. Employee Assistance ProgramThe Employee Assistance Program (EAP) is a worksite program designed to identify and resolve personal and family problems that may adversely affect employee's well-being or job performance. The EAP gives employees a confidential, reliable resource to turn to, 24 hours a day. Standard services include:
For more information on Aurora's EAP, click here. Managed behavioral health servicesTo complement the disease management program, Aurora Behavioral Health Services provides a comprehensive provider network and care management program for your behavioral health needs. By integrating all programs and assigning highly trained case managers to each patient, nonessential duplication of services is avoided and close monitoring and coordinated care throughout each stage of recovery is possible. Practice guidelines and clinical standards are universally applied, guaranteeing consistent treatment from person to person. Aurora Behavioral Health Services provides a wide array of services to ensure that individuals receive the least restrictive and most appropriate level of care. These services include:
Access Employees are provided a toll-free number to call when they have questions about behavioral health issues. The Care Management Center is staffed with Masters level therapists and/or RNs trained in behavioral health. The Care Management Center assesses the severity of the call as either emergent, urgent or routine. Based upon specific assessment criteria, the caller is then directed to the appropriate level of care or provided the information he/she is seeking. If treatment is required, a care management specialist coordinates services for each patient and, if appropriate, communicates information to family members, the employer, EAP professionals and/or to the patient's primary care physician. Outcome monitoring The Care Management Center specialists coordinate services for patient populations with common problems, such as depression, through the use of clinical protocols and pathways. By examining defined populations with common symptoms and socio-demographic needs, Aurora Behavioral Health Services is able to offer programs which obtain measurable clinical outcomes. For more information on Aurora's Behavioral Health Services, click here.
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