Complex Case Management

Individuals with complex care needs require specialized support to help them and their families navigate the complicated health care system. To help these members, Medicaid programs and health plans rely on Commonwealth Medicine solutions to provide person-centered care across delivery settings and policy environments.

Using the most advanced standards of practice, and current policy, quality, and clinical guidelines, our team of experts develops and implements case management programs for individuals who have either complex medical or behavioral health needs that span the disability spectrum. We build thorough documentation for each program, tailoring our outreach and assessment activities depending on each client’s individual needs and applying unique review criterion to determine the appropriate service level.

For every program, our best practice case management models focus on providing the appropriate and highest quality of care in the most efficient and cost-effective setting with the goal of delivering optimal clinical and rehabilitation outcomes, and overall satisfaction of both the individual and our client, including:  

  • Our in-home needs assessments determine medically appropriate long-term services and supports (LTSS), providing individuals with the care they need to live in a community setting. 
  • Nurse case managers serve as a single point of contact, ensuring that care plans are person-centered and support the principles of self-direction and independent living. 
  • An experienced, multi-disciplinary team—including physicians, nurses, respiratory, physical and occupational therapists, speech and language pathologists, pharmacists, social workers, and clinical rehabilitation counselors—collaborates to address the often complex needs of the individual. This includes behavioral health components, psychosocial issues, social determinants of health, and language or cultural considerations that need to be addressed to support community living and employment goals.
  • We coordinate with state agencies and community-based organizations to ensure that services and programs work efficiently and cost-effectively on behalf of the individual.
  • Our health care finance experts help individuals and their families obtain commercial health insurance in addition to Medicaid, and we coordinate payment by the appropriate insurer.

Our Results:

  • Since 1999, we have provided robust case management services to over 5,000 adults and children with disabilities in Massachusetts.
  • Our case management teams have facilitated the transition of nearly 4,000 individuals from hospitals and nursing facilities to community care settings, with appropriate services to address their disability, rehabilitation, quality of life, and community living and employment goals.
  • Our person-centered care plans and identification of duplicative services, have resulted in cost-avoidance savings of approximately $95 million for our clients.