Case management at its best

USFHP takes pride in its work

By J.M. Simpson on July 24, 2022

US Family Health Plan (USFHP) providers pride themselves on offering world-class health care for their patients. This care includes wellness and disease preventions programs, disease management, and the case management.

As to case management, it is a collaborative process comprised of assessment, planning and care coordination to meet the needs of an individual's and family's overall health needs in order to promote patient safe, quality of care and cost-effective outcomes.

For more than eight decades, USFHP has been proud to serve active-duty family members, retirees and their dependents, and Reserve/Guard members on active-duty orders who are under the age of 65.

"The goal of USFHP's case management program is to support the activities of the medical home model by providing real-time case management services to patients," said Everline Kamunya, supervisor of care coordination.

"As they move between settings we build increased awareness of health literacy, promote patient satisfaction, and improve patient safety through excellent transitions of care management."

Kamunya went on to explain that a case management team is comprised of a registered nurse case manager and a social work case manager.

"Each patient who is discharged from the hospital to home or skilled nursing facility to home receives a call from the case manager within two business days of the discharge date to ensure continuity of care," continued Kamunya.

In 2021, USFHP case management teams made 1,433 discharge calls out of a 1,660 total number of members discharged from health care settings.

The purpose of the calls is to ensure that all patients have their needed equipment, know about their follow up appointments, understand their diagnoses and care plan, and have their medications and know what the medications are for and how to take them properly.

"Sometimes we also assist with emergency room transitions," explained Kamunya.

"Once our team is notified that a patient has been to the emergency room, we review the medical record looking for the patient's place of residence, functional status, chronic illnesses, history of falls, mental status, medications, assistance at home and other factors. We then connect with the patient if our engagement can assist facilitate improved patient outcomes or easier access to care."

The case management team will also collaborate and/or consult with a social worker, primary care provider, and clinic registered nurse to help assess patient care and intervene as needed to improve patient safety and health outcomes.

"Our work works," concluded Kamunya.

"One thing that makes our team unique is that we truly care about our members. We care about You, your health and your vitality. We see ourselves as a partner in Your journey. We take immense pride in being able to make that kind of difference."