Complex Case Management Trigger Events

Braven Health’s Complex Case Management Program is a free, voluntary service that offers care coordination and guidance to our members and their covered dependents when faced with a serious illness or condition. The member’s physician and a Braven Health Care Manager will work collaboratively with the member to develop a treatment plan. The treatment plan will consist of both long and short-term goals for our members or their covered dependents to achieve self-management of the illness or condition.

Braven Health identifies members for the Complex Case Management Program from many sources, including:

  • Physician referrals
  • Member self-referrals
  • Predictive modeling
  • Daily discharge logs
  • Weekly re-admission reports

Below is a partial list of trigger events for Complex Case Management services for member referral. Triggers can be a diagnosis, an event, a circumstance or a behavior that represents an opportunity for case management intervention.

Braven Health reserves the right to modify this list at any time.

Trigger Events and Circumstances

  • Acute or chronic medical condition
  • Acute or chronic medical condition associated with an unstable home environment or lack of a qualified caregiver
  • End stage Disease Processes
  • Cognitive rehabilitation
  • Education on out-of-network utilization
  • Emergency Room (ER) readmission for same diagnosis within 30 days
  • Extended acute hospital stay of more than seven days
  • Extended (greater than six weeks) physical, occupational and/or speech therapy
  • Extended (greater than six weeks) home intravenous therapy
  • Extended (greater than six weeks) home health aide (HHA) and skilled nursing
  • High dollar claimant (greater than or equal to $100,000 threshold)
  • Hospital readmission within 30 days, excluding planned admission
  • Member or physician referral
  • Multiple comorbidities without a current treatment plan or unstable disease process
  • Multiple ER visits
  • Pharmacy needs of six or more medications
  • Private duty nursing
  • Severe trauma
  • Specialized durable medical equipment (DME)
  • Ventilator dependent
  • Wound vacuum-assisted closure (VAC) devices

Trigger Diagnosis

  • Anoxic encephalopathy
  • Asthma (inpatient admission greater than two ER visits within 30 days)
  • Autoimmune diseases or HIV/AIDS
  • Cancer diagnosis
  • Chronic kidney disease (CKD)/End-stage renal disease (ESRD)
  • Chronic obstructive pulmonary disease (COPD)
  • Clinical trials – outpatient setting
  • Congestive heart failure (CHF)
  • Coronary insufficiency syndrome
  • Cerebrovascular accident (CVA) – stroke
  • Diabetes (newly diagnosed/one inpatient admission or less than two ER visits within 30 days)
  • Hemophilia
  • Hypertension – uncontrolled (blood pressure)
  • Hypogammaglobulinemia
  • Intracranial hemorrhage
  • Limb amputation
  • Lupus
  • Myocardial infraction (MI) – heart attack
  • Multiple traumas
  • Neuromuscular conditions:
    • Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease
    • Cerebral palsy
    • DiGeorge syndrome
    • Guillain-Barré
    • Huntington’s disease (HD)
    • Muscular dystrophy
    • Multiple sclerosis (MS)
    • Spinal muscular atrophy
  • Parkinson’s disease
  • Pulmonary hypertension
  • Rare diseases
  • Respiratory failure or distress
  • Gender reassignment
  • Sickle cell anemia
  • Spinal cord injury (SCI)
  • Systematic sclerosis
  • Transplant candidates
  • Traumatic brain injury (TBI)
  • Unstable angina
  • Wounds (non-healing/infected or open)

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