Central California  Alliance For Health


Complex Case Management and Care Coordination

Complex Case Management

The Complex Case Management team is a multidisciplinary team comprised of primary care providers (PCP), nurses, medical social workers, and care coordinators that provide the following services:

• Comprehensive assessments

• Promotion of the Patient Centered Medical Home by fostering the
  patient-PCP relationship.

• Care coordination.

• Promotion of self-management through engagement.

• Connecting members to community and social support resources.

• Fostering mutually agreed-upon care plans, including targeted

• Engaging members telephonically and in-person.

• Providing support across the health care continuum.

• Working with a member for up to a 6 month period.

What is suitable for referral to Complex Case Management Services?

(please note this is not an all-encompassing list)

Chronic Illness Catastrophic Diagnosis Medical Issues
Poorly controlled chronic illness or new/worsening complications (e.g. asthma and diabetes)

Obesity/bariatric patients

Medication reconciliation

Multiple admissions (excludes cancer)
Complex injuries

HIV/AIDS (new diagnoses and unlinked)

End of life
Complicated wounds

Stroke with complications

New or worsening debilitating disease (e.g. Multiple Sclerosis, Parkinson’s Disease)

Seizure disorder with complications

What is not suitable for referral to Complex Case Management Services?

(please note this is not an all-encompassing list)

Members with other health care coverage Disruptive, violent, or abusive behaviors Members who are unable to be reached or who refuse to participate Members in Long Term Care

To refer members to Care Management Services, please complete the form below and fax it to (831) 430-5852, ATTN: Case Management.


Case Management Fillable Referral Form

Care Coordination

The Care Coordination team assists members with less complex, non-clinical needs by providing:

• Referrals to community resources and services.

• Follow up care with specialists, including referrals for ancillary
  services and durable medical equipment (DME).

• Assistance with making appointments and retrieval of medical records.

• Appointment reminders and linkage to transportation resources.

• Children’s care management for members less than 21 years old
  with special health care needs who require assistance and linkage to services.

For information about or referrals to Care Management Services, including Complex Case Management and Care Coordination, please call the Case Management line at (800) 700-3874 ext. 5512.


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