NY Manual
SHP Manual

SHP Provider Manual
2.5 Impaired Members | 3.2 Coordination of Services

Section 3 - Care Management Teams

3.1 Care Management

Care Management is a process that ensures consistent oversight, coordination, and support to members and their families in accessing Managed Long Term Care covered services, as well as non-covered services. Working with members, the Care Management team develops a care plan of all services members require.  The mutually agreed upon care plan is reviewed and revised over time in response to the changing needs of the member. Senior Health Partners is dedicated to the provision of services that will enable members to remain safe and secure in their own homes.
 
Upon enrollment, a member will be assigned to a Primary Care Manager (PCM). Their PCM is responsible for managing the member's chronic health problems, supported by the Clinical Consultant Team (CCT), including a nutritionist, nurses, and social workers with specialized knowledge of various clinical topics, and ample support staff to assist with the member’s care. The Primary Care Management Team monitors changes in their health status, provides appropriate care, and encourages self-help. Members may request to change any member of their Primary Care Management Team at any time.
 
The Primary Care Management Team is available to assist the members with any issue.
 
The Primary Care Management Team will “coordinate services” the member receives, and will communicate with the member's doctors on an ongoing basis. Coordinate services” means that the Primary Care Management Team may arrange appointments for the member, arrange for transportation to and from appointments, and communicate with other care providers, regarding services covered by Senior Health Partners, as well as services not covered by Senior Health Partners.
 
When needed, the Primary Care Management Team may also help a member modify the member's home to improve safety and convenience and coordinate for assistance from family, friends, and neighbors.
 
By helping the member manage all aspects of their care, the Primary Care Management Team can identify problems early, prevent problems from getting worse, and help the member avoid trips to the hospital and emergency room