CHNCT’s Care Management program includes Intensive Care Management (ICM), and Transitional Care Management (TCM), which focus on the complex care management of members with multi-morbid conditions, barriers to optimal care, and psychosocial needs. ICM provides comprehensive case management services that aim to increase member engagement in ongoing care with a primary care provider (PCP), decrease potentially avoidable hospitalizations, and reduce health disparities through multi-disciplinary, person-centered care and care coordination. Transitional Care services support smooth transitions from a healthcare facility to home, and participation in recommended follow-up care. By responding to members’ individual needs, the Care Management program provides focused care coordination resulting in improved patient participation for better health.
The Care Management Team can help your patients by:
Our certified Community Health Workers (CHWs) serve as ambassadors for the HUSKY Health program and help families access community resources for the services they need. They are committed to help building equity through diversity, inclusion, and community engagement efforts. They work to ensure that all members, regardless of ability, age, cultural background, ethnicity, faith, gender, gender identity, ideology, income, national origin, race, or sexual orientation have the opportunity to reach a better quality of health.
CHWs provide the following patient assessment and referral services:
Our nurses help members who have recently been to the emergency department or hospital and may need assistance understanding the discharge plan and medications. We can help make sure that a follow-up appointment has been successfully scheduled with the provider, and that transportation arrangements have been made. Our nurses can also answer members’ questions about their condition, share health-related information, and help them get connected to needed services.
Our nurses help members who have chronic (long-term) health conditions, especially when they cause frequent hospital visits, to find a primary care provider and any other specialty providers needed. We coach members on the importance of having an Action Plan, knowing when/how to follow it, and what to do if symptoms get worse. Our nurses also answer questions about different medications and reasons for taking them and can help with any problems the member may be having with their medication plan.
This program is for those who are pregnant or have recently given birth and have certain health and social risk factors that may require special monitoring or attention. Nurses work with pregnant members and their families to support successful engagement in recommended care with their provider, address risk factors, and resolve barriers to obtaining needed services and supplies. They also provide education on pregnancy-related topics, such as breastfeeding, important warning signs/symptoms during and after pregnancy, and adjustment to the postpartum period.Learn more
Our nurses work with members to help coordinate complex care among their healthcare team. This includes providing support to members awaiting an organ transplant or receiving gender-affirming services. We can help navigate benefits, provider access, and treatment requirements or instructions. Our nurses can also help coordinate necessary healthcare services.
Our nurses help members who have sickle cell disease improve and maintain their health. We can assist members with managing appointments or setting up health services. We coach members on the importance of having a Sickle Cell Action Plan, knowing when to follow the action plan, and knowing what to do if symptoms worsen. Our nurses work with the provider and the member to reinforce their treatment plan. We can also support members and their families when transitioning to adult clinics.
This program is for babies who are born early, or who need special care after birth. Our nurses work with families, hospital staff, and providers to help support these special babies and their development. This includes sharing health-related information and helping families get connected to care and services they may need.
This portion of the HUSKY Health website is managed by Community Health Network of Connecticut, Inc.®, the State of Connecticut’s Medical Administrative Services Organization (ASO) for the HUSKY Health program. For the general HUSKY Health website gateway, please visit portal.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services (DSS).