Communitas provides a complete portfolio of innovative healthcare management solutions to assist in effectively managing our client’s healthcare dollars. Within each of our products, we work closely with our clients to pinpoint how successful healthcare management will be defined and aggressively work toward achieving agreed upon results through leading edge, technology, reporting and face-to-face interactions with our clients. By doing the initial upfront work, we can bring clarity to chaos.
Utilization Management
Telephonic Case Management
Maternity Management
Wellness and Health Coaching
Nurse Case Review
Chronic Condition Management / Disease Management
Utilization Management
Determine medical necessity and appropriateness — initiate intensified nurse intervention.
UM has a sentinel effect with treating providers, averts medically unnecessary or inappropriate procedures, and serves as a referral mechanism to large case management and chronic condition nurse managers. Our Utilization Management RNs follow inpatient hospitalizations and procedures by conducting continued stay reviews to ensure that all days are medically necessary. UM is performed on the following:
- Inpatient hospital
- Outpatient surgeries and imaging
- High-cost medical services
Telephonic Case Management
Develop programs and coordinate care for individuals with high disease burden and costs — conditions where health improvement is not likely.
- Help patient and family navigate clinical and financial elements of healthcare
- Provide payer with updated clinical status information and recommendations to improve the patient’s recovery and lower cost to the plan
- Assist with identifying lower cost, comfort-driven care alternatives
- Negotiate reductions in provider fees
- Advocate for patient and support family and provider
Maternity Management
Deliver valuable education and assistance to expectant mothers, resulting in healthy babies and happy mothers.
- Reduce high-risk childbirth-related expenses, which are among the highest costs facing employers
- Provide support from an experienced Registered Nurse counselor
- Help prevent premature/low birth weight infants and reduce C-section rate
- Minimize pregnancy-related complications
Wellness and Health Coaching
Identify unknown health risk of total population.
- Proactive employers can lower absenteeism, improve productivity and increase employee satisfaction by using effective wellness strategies
- Personal health assessments
- Biometric screenings (e.g. BMI, blood pressure)
- Lab work (e.g. glucose, cholesterol)
- Immediate emergency interventions for significantly abnormal screening and lab results
- Detailed individual and company reporting
- Highest levels of patient privacy are ensured
Nurse Case Review
Strategically predict future large claims and advocate with carriers for best case underwriting.
- Analysis of claims history is used to predict large claims over the next 12 months
- Provides background on stop loss terms and underwriting
- Prediction of treatments that may be needed
- Assistance with high claimant drugs and other cost saving solutions
Chronic Condition Management / Disease Management
Communitas identifies potential members for our Chronic Condition Management / Disease Management (DM) program through referral from other clinical areas, analysis of claims data, and through predictive modeling.
- Stratification process identifies members as low-risk, emerging-risk or high-risk. Our nurses focus on the emerging and high-risk categories when making outreach to members.
- Identification of pain points through data analysis of individual client populations allows our team to prioritize disease states that are impacting the health plan.
Once enrolled into the DM program, an assessment is performed to gauge a member’s readiness and willingness to accept and learn new information that could impact their health.
- This is revisited throughout the member’s enrollment in the program to assess progression along the readiness and willingness scale.
- Collection of the member’s medical history and current medical and social conditions are taken into account to develop realistic goals for the member to strive towards, always working toward educating the member and caregivers and giving them tools and resources to self-manage their care in the future.