Population Care Management (PCM) Programs and Services

Obstetrical Care Management

• Members access this program by responding to pregnancy outreach letters and receiving subsequent positive screening by the SoonerCare Member Services department.
  • Effective 10/4/2019, women in Tulsa County will receive an alternative outreach letter directing them to the ConnectFirst program.
   
• A nurse care manager then completes a health assessment on the member, links the member to resources, and conducts routine follow-ups with the member throughout the pregnancy.
• Member receives assistance in accessing various resources and services for the newborn.

• Provider initiates High-Risk OB program through the medical prior authorization process. Learn More Here
• Once approved, member receives enhances HROB benefit package and nurse care management follow-up throughout the pregnancy.
• Member receives assistance in accessing various resources and services for the newborn.

• Members are also identified for OB Care Management if they are prescribed certain medications for a history of pre-term labor.
• Members and Providers can request OB Care Management directly by contacting the Population Care Management Department.

Pediatric Care Management

• All newborns born to mothers in designated counties with the highest infant mortality rates are enrolled in this program. Parents are contacted by a Social Services Coordinator (SSC) who will assess for necessary social needs such as housing, food, utilities, transportation and safety. The SSC will help with resources to meet those identified needs.
• The SSC also screens the mother for post-partum depression and screens the child for chronic conditions.
• Subsequent referrals may be made for Nurse Care Management support or for Behavioral Health services if needs are identified.

• Providers access program through medical prior authorization process or inquiry into private duty nursing (PDN) services.
• Nurse Care Manager does face-to-face assessment that is utilized by a physician in the Medical Professional Services Unit to determine qualification for PDN services.
• Nurse Care Manager provides periodic reassessments (telephonic and face-to-face) for Private Duty Nursing services, as well as Care Management support.

Other Care Management Services

Oklahoma Cares - Breast and Cervical Cancer Treatment Program

• This program provides SoonerCare benefits to qualifying women in need of treatment (including diagnostic services) for breast and/or cervical cancer. This program is a partnership between OHCA, Oklahoma State Department of Health, Cherokee National and Kaw Nation. Specific medical and financial criteria must be met to qualify.
• Application for the program is initiated by a certified screener. To find a screener:
  • Oklahoma State Department of Health: 866-550-5585
  • Cherokee Nation - 800-256-0671 Ext. 5442 or 918-453-5442
  • Kaw Nation - 580-362-1039 Ext. 229
   
• Care Managers in Population Care Management participate in the clinical review of applications and provide care management services to women through their enrollment in the program.

• Nurse Care Managers provide care coordination to members in need of services that are a significant distance from their home, generally 100 miles or more, and/or out of state.
• These services often involve coordination of the authorization to receive care, transportation assistance, and meals/lodging assistance.
  
  

• Nurse Care Managers participate in the clinical review process for members seeking Long-Term Care Services through:
  
  • Program for All-inclusive Care for the Elderly (PACE)
  • Medically Fragile Waiver Program
   

• Social Coordinators assist with community-based service referrals such as support groups, food banks and utility assistance.
• Social Service Coordinators review and coordinate requests related to meals and lodging for the distant care services described above.

• Care managers work with primary care providers and members to coordinate and overcome barriers that may lead to misuse or overuse of ER services.

• Care management is available for members with complex care coordination needs. Care managers work with primary care providers and members to coordinate services and follow-up support.