Care Coordination

Every member that participates in the CareSource PASSE™ program receives care coordination.

The Care Coordinator will support the member and facilitate the care team by:

  • Assessing each member’s needs
  • Developing, implementing and monitoring the person-centered service plan (PCSP)
  • Educating the member and their caregiver/family
  • Monitoring of services
  • Establishing linkage not only to paid providers but free community resources such as family service agencies, court systems, local mental health agencies, food banks, schools, pharmacies, primary care doctors and other appropriate paid and non-paid resources.

We stress the importance of establishing a medical home, identifying barriers, keeping appointments and expressing needs. The Care Coordination model also utilizes specialty care management teams comprised of medical and behavioral health nurses, social workers, licensed professional counselors, community health workers and outreach specialists. We have pharmacists on staff to assist with medication reconciliation and function as a part of the interdisciplinary care team.

You can access care plans online through the Provider Portal to easily provide input into your patients’ care plans and consult with care managers.

Enrolling in Care Coordination

Members can call 1-833-230-2005 24 hours a day, seven days a week to access care coordination services. All CareSource PASSE members are assigned to a specific care coordinator they will be working with while a part of the PASSE. If, however, a member is unable to reach their assigned care coordinator or have not had contact with them yet, they can call Member Services to receive care coordination services. Additionally, providers may call Provider Services to identify who a member’s care coordinator is or to speak to a care coordinator supervisor. Providers may also identify a member’s Care Coordinator on the Provider Portal (coming soon).

Disease Management Programs

Our free disease management programs help our members find a path to better health through information, resources and support.

We help our members through:

  • The MyHealth online program for members 18+ to participate in a journey to improve their health
  • Care coordination to provide disease management information and materials to members and providers with helpful tips to manage their disease, promote self-management skills and provide additional resources, as needed
  • One-to-one care coordination

Members with chronic health conditions are identified by criteria or triggers such as emergency room visits, hospital admissions and the health assessment. All ages (children, teens and adults) are eligible. These members are automatically provided with condition-specific materials. The materials are available in English and Spanish. The member’s Care Coordinator works with the Disease Management team to distribute information to members and providers. Any member may self-refer or be referred into disease management programs to receive condition-specific information or outreach. If members do not wish to receive materials or outreach, they can call 1-844-438-9498.

How to Refer Members to Disease Management Program

If you have a patient with a chronic health condition who you believe would benefit from a program and are not currently enrolled, please call 1-844-438-9498.