Transitional Care Management: A Care Navigation Program


In September 2019, as a part of our contract with the New Hampshire Department of Health and Human Services (DHHS), our New Hampshire (NH) Healthy Families Medical Management Leadership team developed and went live with a transitional care management (TCM) program in concert with the contract requirements. The TCM team at NH Healthy Families supports and collaborates with our network facilities to effectively manage our members while they are in the acute inpatient setting. The TCM team works directly with the hospital/facility to identify solutions for discharge to home, or to an alternative setting. The TCM team functions as a care navigation program, meeting the member where they are and allowing NH Healthy Families to partner with our facilities and providers to assist patients in achieving their discharge goals.

The team is composed of registered nurses, licensed practical nurses, social workers, behavioral health clinicians, and support coordinators who are non-clinical and have care coordination/managed care experience. This team seeks to assist members at all levels of care. The NH Healthy Families TCM team helps members transition through the care continuum to reduce readmissions and provides resources and education to help patients understand their condition and support their unique, individualized health care needs.

Our facility selection included screening and identifying where the highest volume need exists in our market through a variety of data sources, including our inpatient daily census, looking at highest volume facilities by authorization, and readmission reports. We also conducted on-site facility engagement to demonstrate benefits to the facility and the member since the focus of this program is on the member and not utilization management.

At NH Healthy Families, some of our network facilities and hospitals are connected to an admission discharge and transfer (ADT) feed portal. This portal allows us to have on-demand and near real-time access to inpatient admissions and emergency department (ED) visits. In addition to obtaining inpatient admission and ED notifications, we can stratify the data to work on creative and innovative population health programs. The ADT feeds allow us to create cohorts for outreach for specific subpopulations. An example is our ED substance use disorder (SUD) program, which is a requirement of our state contract as well. This ED SUD program is staffed by two individuals, one with an emergency response background and one who is a licensed alcohol and drug counselor (LADC). The focus of this program is to conduct prompt outreach to members who have recently had an ED visit with an SUD diagnosis. Our team makes three attempts over three days to reach the member to assess their needs and provide a support plan for next steps in their treatment.

After the high-volume facilities were identified, our TCM team had to develop relationships with the hospital case management team, prepare for on-site member management, connect with facility staff, attend patient care rounds, conduct face-to-face visits, complete discharge screenings, and review the interventions for any recommendations and support that may be needed. The TCM establishes a relationship with the member and works to assess the discharge instructions to ensure a solid understanding by the TCM and the member/family/caregiver. Examples of elements that may be reviewed include but are not limited to medication lists, post-discharge follow-up appointments, medical equipment prescribed by the member’s doctor, and home health if ordered by the member’s doctor.

The members our TCM team targets are identified as high risk and having multiple co-morbidities, based on a proprietary risk score. If the risk score screens individuals into inclusion, the next step is for the member to have a pre-discharge screening visit, ideally face-to-face, while the member is still an inpatient. In addition to the screening and identification via scoring, the TCM will connect and collaborate with their hospital discharge team to see if there are other members enrolled in our health plan that they may be able to assist. The team will work directly with the facility, member, family, caregiver, providers, and primary care physicians (PCP), as indicated based on the members individualized plan of care.

The TCM schedules a time to conduct a post-discharge transition of care assessment and conducts post-hospital outreach. From an outcomes perspective, we have seen an increase in both our 3-day post-hospital outreach metrics and 10-day post-hospital outreach metrics. In addition, we have seen success stories from both the providers and members. Success stories include both member care transition and overcoming provider challenges at the facility that resulted in barriers to moving the discharge forward and achieving a successful transition.

The TCM team will engage with the inpatient discharge planners, case managers, and social workers on high-risk members who have continued care needs upon discharge to coordinate appropriate follow up. Follow up may include but is not limited to:

  • Ensuring outpatient appointments are set up
  • Following up with the discharge planning team to ensure home care needs are met (such as home health and durable medical equipment)
  • Collaborating with facilities, providers, and members to ensure community resources and supports are provided (e.g., waiver services, services provided by a faith-based organization, Meals on Wheels)
  • Evaluating continued behavioral health conditions upon discharge from an inpatient behavioral health facility or residential treatment center, collaborating with high-volume network facilities within the NH Healthy Families network to conduct on-site meetings to determine needs
  • Coordinating with external teams (e.g., hospitals, integrated delivery networks)
  • Attending on-site care planning and care transition meetings
  • Engaging with internal teams and interdisciplinary professionals (such as care managers, program specialists, program coordinators, foster care liaison, and care management leadership).

The TCM will continue to follow the member for two weeks post-discharge and identify long-term care management needs. If there are care management needs that result in care management enrollment, the TCM will work with our internal care managers to ensure a smooth, warm handoff. The TCM will also consult with the care manager so that all relevant information is communicated to develop the care plan. The care manager will subsequently complete a comprehensive assessment, develop a care plan with problems, goals, and interventions based on the member’s current condition, and revise the plan of care if there is a change in condition.

The goals of the program include reducing the ED visit rate, increasing the post-discharge follow-up success rate, decreasing the average length of stay (ALOS), and increasing care management enrollment. Overall, we have seen a reduction in the ED visit rate and an increase in post-discharge follow-up rates, which are metrics we are very proud of. We continue to work on strategies for ALOS and care management enrollment maximization. Our team members who fill these roles have verbalized how much they love what they do and that they are very satisfied with their jobs. Of note, due to the global pandemic of COVID-19, we did stop facility and face-to-face visits in March 2020 with the hope of resuming those interactions when the restrictions are lifted. The TCM teamwork continues through telephonic and electronic methods to ensure our members’ care needs are met, our facilities and providers are supported, and that we remain focused on optimal care outcomes.

jonathan j. morello

Jonathan J. Morello, MSN, RN, CCMis vice president, medical management – NH Healthy Families. Jonathan has been with Centene Corporation (NH Healthy Families) since December 2013. Jonathan has a background in managed care as well as clinical experience in neurosurgical critical care, medical/surgical and geriatrics. Jonathan holds a master of science in nursing degree with an emphasis in healthcare systems leadership from the University of Arizona in Tucson. Jonathan is a Certified Case Manager and is a member of Sigma Theta Tau International honor society of nursing. Jonathan is currently pursuing a master of business administration at Louisiana State University Shreveport. Jonathan has a passion for population health and under-served populations, specifically ensuring gap closure and warm hand-offs across the continuum of care. In his free time, Jonathan enjoys traveling and spending time with family.

Erica W. Oberman

Erica W. Oberman, BSN, RN, CCMis currently the director of utilization management at Centene Corporation. Erica has been with Centene Corporation since December 2013. Erica has a background in managed care as well as clinical experience in progressive care and medical/surgical. Erica holds a bachelor of science in nursing degree from Curry College. Erica is a Certified Case Manager and is a member of Sigma Theta Tau International honor society of nursing. Erica is currently pursuing a master of business administration at Louisiana State University Shreveport. Erica has a passion for transitional care management and patient education. In her free time Erica enjoys traveling, and spending time with her husband and her two children.


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