Referrals

Reasons to refer for CCM may include but not limited to:

• DM A1c >8%, unmanaged and increasing
• HF new onset and/or frequent exacerbations. HF are patients eligible for remote patient monitoring (RPM) 
• COPD frequent exacerbations
•  Asthma
• HTN uncontrolled
• High ED Utilization
• High Risk Medications (ie., high cost, anticoagulants etc)
• ED/readmission risk score >55% and increasing
• Medication/treatment non adherence
• 3 admissions/readmissions over 12 months
• Chronic conditions with 2-3 admissions over 12 months or 3 or more ED visits over 6 months

Note: Complex pediatric patients who need ongoing care management support should be referred to the health plan by calling the customer service number on the back of their insurance card and requesting to be connected to a case manager.

Reasons to refer to MSW may include but not limited to:

• Anxiety - GAD score 5+ without current interventions, support or resources, or support is not a good fit
• Depression - PHQ2/9 5+ without current interventions, support or resources, or support is not a good fit
• Coordination of Services to other appropriate professionals & services
• Stress - support & coping strategies
• Advocacy, education & resources
• Substance abuse

Note: MSW cannot follow Pediatric patients or those with Developmental Delays due to specialization but can assist caregivers to locate resources for patients.

Reasons to refer to CHW may include but not limited to:

• Addresses Barriers related to Social Determinates Of Health (SDOH).  Examples include: Transportation, copays, utilities, food scarcity, housing/un-housed, financial resource strain, etc. 
• Advocacy
• Community Resources
• Medicaid support/lapse

TCM referrals are automatically received from hospital admission/discharge reports which are sent to us daily.  You are able to see the TCM RN information in Epic in the Care Team. If you think a patient with a recent admission is NOT already being followed by TCM, please complete the referral form and we will verify if they are eligible for TCM.