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Complex Case Management


Care1st has established a Complex Case Management Program to provide a direct interface with our members and work closely with their physician to coordinate care and services to high-risk members. The goal of Complex Case Management is to help members regain optimum health or improved functional capability, educate members regarding their chronic condition and reinforce the PCP prescribed treatment plan.

Care1st utilizes two distinct processes to identify members for enrollment in Complex Case Management that includes both administrative/electronic data and/or referral sources. Administrative data reports are reviewed on a minimum of a monthly basis, referrals are concurrent.

Electronic identification sources include but are not limited to the following:

  • Claims Data
  • Encounter Data
  • Hospital Discharge Data
  • Pharmacy Data
  • Laboratory Data
  • Medication Therapy Management Program

Referral identification sources include but are not limited to the following:

  • Provider Referrals
  • Disease Management Program Referrals
  • Discharge Planner (Inpatient Case Manager)
  • Member Self-Referral
  • Member Services Referral

Referral Process

Any Care1st Healthplan credentialed PCP/Specialist may refer a member to Complex Case Management.
Each referral will be reviewed for enrollment in Complex Case Management based on available information and telephonic member assessment. Participation in this program is free and voluntary for all eligible Care1st Health Plan members. You can refer a member to this program by filling out this form.

If you want additional information or would like to discuss the Care1st Health Plan Complex Case Management Program you can call 323-889-6638 x6291 or you can fax the Referral Form and/or additional documentation/information to 323-889-6575.

Enrollment Criteria for Complex Case Management

  • Major Organ Transplant
  • Major Trauma
  • 4 or More Chronic Conditions
  • 3 or more Admits within a 12 Month Period
  • Readmission with Thirty (30) Days with the Same/Similar Diagnosis/Condition
  • Polypharmacy Utilization Consisting of >30 Prescriptions per Quarter
  • Diagnosis of cancer requiring multiple modalities of treatment with complex coordination of care across multiple disciplines

Chronic Conditions

  • Diabetes
  • Renal Failure
  • Hypertension
  • Pulmonary:
    • COPD, Pneumonia, Asthma, Respiratory Failure, Pulmonary HTN, Guillain-Barre Syndrome
  • Cardiac:
    • CHF, Cardiomyopathy, CAD
  • Osteomyelitis
  • Rheumatoid Arthritis
  • SLE
  • Multiple Sclerosis
  • Parkinson's Disease
  • Cirrhosis of Liver / Chronic Liver Disease
  • Pressure Ulcers
  • HIV
  • Metastatic Cancer

Primary Care Provider Notification Process

After the member is enrolled in Complex Case Management the PCP is notified in writing of the member's enrollment and an explanation of the CCM Program and Complex Case Manager contact information.

The PCP will periodically receive written correspondence from the Complex Case Manager for a clinical status update on their member.

The Complex Case Manager is required to telephonically contact the member's PCP when there is a change in member condition and to coordinate care/services when applicable.



Care1st Health Plan has established a Disease Management Program to provide education, care coordination and support to our members with certain chronic conditions.

The following Care1stCARES Programs are available:

  • Asthma and CHF

Care1st refers to these programs as Care1stCARES. Participation in these programs is free and voluntary for all program eligible Care1st Health Plan members.

These programs provide the member with the education necessary to better manage their condition. Our Disease Management nurse will work closely with the member and their doctor to help keep them as healthy as possible and avoid unnecessary hospitalizations. The nurse will assist the member in coordinating their care and obtaining all required preventive health screenings.

All Programs are administered by Care1st Health Plan. Care1st automatically identifies members with these medical conditions who meet specific criteria and offers them participation in these programs. The more you learn about these conditions and the medicines used to treat it, the better you will be able to work with your doctor to control it. In order to help you meet these goals, Care1stCARES provides these programs to you.

Benefits to the Member

  • Regular Nurse Calls - telephone contact from our disease managers to review the member’s health status and provide support and education.
  • Telephone Support – toll-free number available for our members to speak with our Disease Manager about their condition and answer any questions they may have.
  • Reminders - to obtain preventive health screenings, exams and tests as needed.
  • Educational Mailings - to help understand the member’s chronic condition.
  • Peak Flow Meter - (for Asthma only) ages >5 to help better manage and monitor the member’s condition.

Benefits to the Physician

  • Member Compliance - with physician treatment plan
  • Detailed Reports - informing you of member’s status changes, or concerns that may require physician intervention
  • Comprehensive Member Medication Profile
  • Care Coordination - with PCP and Specialists.
  • If you want additional information or would like to discuss Care1stCARES Programs with our Disease Manager, you can call (866)-991-8222
  • You can refer to these programs by filling out this form.