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 nurses, medical social workers, and care coordinators who partner with PCPs to provide the following support for members for up to a six-month period:

• Comprehensive assessments

• Promotion of the Patient-Centered Medical Home by facilitating a
  safe connection between our members, their caregivers, and their PCPs

• Care coordination

• Promotion of health self-management efforts

• Referrals to community resources

• Mutually agreed-upon, individualized care plans that include targeted

• Patient engagement through phone and in-person encounters

Which patients are suited for referral to Complex Case Management Services?

(Note: this is not an exhaustive 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

Which patients are not suitable for referral to Complex Case Management Services?

(Note: this is not an exhaustive list)

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 and keeping appointments

• Assistance with the retrieval of medical records

• Linkage to transportation resources

Providers can refer Alliance members to Care Management Services, including Complex Case Management and Care Coordination, by calling Case Management at (800) 700-3874 ext. 5512. You can also fax a completed referral form (click the link below) to (831) 430-5852, ATTN: Case Management.

Case Management Referral Form


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