Premera offers a range of care
management services and programs for providers. These programs
help members navigate the healthcare system with a range of options available
- Determine coverage for specific services and procedures;
- Provide care coordination and support for complex medical conditions, and
- Provide care education and planning guidance ahead of a planned hospital stay or following discharge and transition to the
Care management programs
Personal Approach to Health (PATH)
The PATH model aims to improve people’s lives through a collaborative, multidisciplinary care advising approach to care. The goals of the PATH
approach are to improve the quality of care, enhance the patient’s experience, and reduce the total cost of care by appropriately using medical resources.
The care advising team includes a medical director, nurses, trained care coordinators, community health workers, and social workers. The care advising team works with
primary care providers (PCPs), specialists, and home care agencies, among others, to coordinate follow-up care and support adherence to provider-developed care and treatment plans.
Programs available to eligible patients:
The Complex Care program is a
collaborative initiative that engages a multidisciplinary care team consisting
of management staff, contracted physicians, and providers including contracted
network hospitals and other relevant stakeholders (community services, home
care, durable medical equipment, behavioral health, etc.). The program includes
collaboration with acute care hospitals, nursing, social services, medical
staff, pharmacy, emergency and quality departments. The program focuses on
patients identified through a combination of claims data and referrals from
providers, members, and caregivers.
- Improve care coordination for patients across care settings.
- Optimize chronic care management.
- Educate patients about diagnoses and self-management.
- Implement care plans for high risk members and members with complex care needs.
- Improve medication compliance.
- Address member/caregiver needs regarding adequate support and resources at home.
- Improve adherence to the hospital discharge care plan for patients discharged to home.
- Decrease “avoidable” utilization events, such as readmissions.
The Transition Care program provides
members with tools to help them get and stay well during the critical period
after a hospital admission. The goal is to decrease their chances of returning
for readmission to the hospital after they have been discharged.
Eligible members prioritized for outreach receive a personalized transition care advisor who works closely with
the member and their care team (both inpatient and ambulatory). The care advisor’s main objectives are to:
- Proactively identify members who are at high risk for readmission based on clinical,
social, and psychological/behavioral factors.
- Educate members on their conditions and potential pitfalls.
- Review the member’s discharge plan and identify potential barriers.
- Ensure appropriate post-discharge follow-up.
- Make sure care is coordinated after discharge between primary care providers, specialists, and
others (home health, infusion, etc.).
- When appropriate, conduct basic medication reconciliation, sometimes in conjunction with clinical
- Develop a post-discharge plan of care which includes contingency planning in case the member develops
new or worsening symptoms.
Behavioral Health Care
The program takes an enrollee-centered
approach to care and collaboration between the multidisciplinary team,
including the PCP. This ensures the enrollee receives the appropriate care
interventions and level of motivational and emotional support that aligns with
their readiness for behavior change. Specifically, this behavior change refers
to behavioral and physical health needs; lifestyle risks; personal preferences
and goals; and psychosocial, cultural, and educational needs.
Eligible members prioritized for outreach receive a personalized transition care advisor who
works closely with the member and their care team (both inpatient and
ambulatory). The care advisor’s main objectives are to:
- Support enrollees in achieving optimal behavioral health, everyday functioning, and improved quality of life.
- Support enrollees in overcoming barriers to treatment and recovery.
- Prevent behavioral health condition related exacerbations and complications.
How to refer a patient for care advising programs
Providers can refer eligible Premera members to care advising programs or ask questions about the programs by calling 800-607-0546. Representatives are available from 8 a.m. to 6 p.m., Monday through Friday. Referrals can also be made via secure fax at 206-806-7455.