Case Management

Gladly accepting online referrals Case Management Referral Form (centralhealth.net)

Enrollment Criteria:

• Active MAP or MAP Basic enrollment
• 18 years and older
• Consents to receive CM services
• Active phone number/ability to contact
• One chronic condition with recent changes
• AND one or more of the following:
  • Social concerns such as transportation, housing, food insecurity, the inability to afford medications.
  • Frail elderly: 65 years and over w/o support system, experiencing homelessness or does not qualify for Medicare/other funding.

Ineligible for CM Services:

• Individuals less than 18 years
  • The patients are assisted via PCP or their specialty care provider
• Inactive MAP or MAP Basic
• Individuals who do not meet the disease condition criteria above
• Individuals receiving case management services elsewhere
• Individuals with Alzheimer/Dementia without family support
  • There are various community resources or Adult Protective Services report via PCP office
• Individuals without an active phone
• Individuals outside of Travis County

Mission:

Work collaboratively with health care providers to identify individuals and provide high quality, cost-effective, person-centered case management and social services to improve health outcomes.

Vision:

Our team serves as a bridge to connect the most vulnerable populations to the care they need at the most appropriate time and place

Values:

• Education & Engagement: Enables individuals and families to become educated and engaged in their own healthcare
• Collaboration & Coordination: Empowers organizations across the healthcare spectrum to coordinate and collaborate in service of individual and community health
• Assessment & Navigation: Facilitates comprehensive assessment of patient barriers to health and connection to delivery of needed resources

Objectives:

• Improve the quality of life for our patients.
• Facilitate access to appropriate clinical and social services.
• Increase patient stability and health to seamlessly transition them into the next resource
• Empower patients, providers, and partners by fostering education and connectivity to community resources.