Chronic Care Management / Disease Specific Management
Members work with a nurse care manager or member of the care management team to better understand their chronic and complex medical conditions.
This assists with coordination with community providers, improving adherence to treatment plans, managing medications, receiving support and advocacy, setting goals to improve self-management skills, and connecting with community resources.
Transitions of Care
Members work with a care manager after transitioning home from an inpatient setting. The care manager will review the discharge plan, provide patient education, review of signs and symptoms of an exacerbation, complete a medication reconciliation, assist with coordinating services or obtaining needed medical equipment, and confirm follow-up appointments with providers and connection with community resources.
Transitions of care outreach is available for members discharged from both medical and mental health inpatient stays.
Mental Health
Members with either a mental health or substance use diagnosis work with a social work care manager who provides support and advocacy.
This includes patient education, collaboration with providers or assistance finding therapy or rehabilitation services, connection with community resources, and using motivational interviewing techniques to drive behavior change and improve self-management skills.
Maternity
Members work with a nurse care manager to receive maternal health support and education during and after pregnancy to promote positive health outcomes for both mothers and newborns.
To refer a member to a care manager at Martin’s Point, visit our Forms and Documents page or call 1-877-659-2403.
Extended Care Health Options (ECHO)
Extended Care Health Options (ECHO) program provides supplemental services for active-duty family members with qualifying mental, developmental, or physical disabilities. Echo offers integrated services and supplies beyond what is covered under TRICARE® plans.
Our care managers can assist with the ECHO registration process and assist with resources and services needed.