Members living with a mental health or substance abuse concerns, may receive confidential care management support and coordination of care from a licensed clinical social worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders.

Complex care management provides care management services for members with one or more complex medical conditions and over or under utilization of health care services. Johns Hopkins Health Plans recognizes that individuals often have two or more health problems that can be well served by evidenced-based care management. Licensed clinical social workers or registered nurse care managers partner with members and providers to assist adult members in learning about their diagnoses and improving their skills in managing chronic health conditions like asthma, diabetes, cardiovascular conditions, chronic obstructive pulmonary disease, sickle cell, cancer, pain management, Alzheimer's, rehabilitative needs, HIV/AIDS, seizure disorders, developmental disabilities, chronic kidney disease and chronic lung disease. We also partner with member’s parents and/ or caregivers to provide services to children 18 years and younger with chronic conditions such as asthma, diabetes, sickle cell disease, neurological devastation, various genetic syndromes, cancer and morbid obesity, or after an organ transplant.

Services include:

• Complex Care Management Assessment completed on all members
• Coordination of transitions of care support services for members in all service areas
• Coordinate care with PCPs, specialists, DME/service providers
• Support self-management
• Address barriers and gaps in care by creating innovative solutions and involving community resources
• Education on signs and symptoms of worsening disease

JJohns Hopkins Health Plans Health Educators are a wonderful resource for all of our members and providers. Our educators advocate, encourage and teach about healthy lifestyles and living well with a chronic condition. Members in special need of educational efforts are identified and assisted with the education needed to meet their needs.

Services can be delivered through the following educational methods:

• Health education classes (synchronous and asynchronous) and activities: view our program descriptions and current class dates and times at the member’s health plan website under Health and Wellness > Health Education.
• Development and distribution of health-related newsletters, fact sheets, and brochures
• Collaboration with case managers in providing member education to reinforce member’s treatment plans

Health Educators can be reached by calling 1-800-957-9760 or email to [email protected]

Maternal - Child Health (MCH) care management is available to prenatal and postpartum members, families with newborns and children. Members partner with a registered nurse care manager to receive support in connecting to services and resources. We offer health education, community resources, care coordination and promote access to quality health services. We strive to contact and engage with members as soon as possible. With family engagement in goal setting, we improve self-reliance and build confidence in navigating the health care system.

• Pregnancy Support - OB nurse care managers provide pregnancy support to pregnant members with high-risk conditions such as pre-term labor, substance abuse, hypertension, asthma, diabetes, or adolescent pregnancy. Social determinants of health are assessed and barriers influencing a member’s engagement in prenatal or postpartum health are addressed. Care managers coordinate the member’s care with OB providers, maternal-fetal medicine and/or other specialists during pregnancy. We encourage member participation in prenatal care, medication management, healthy eating, safe home environment, stress reduction, self-care and improved emotional health. Members remain in care management after delivery expanding the opportunity for member care in the postpartum period.


• Support for infants and children - Pediatric nurse care managers engage with members 18 years and younger with risk factors that include, but are not limited to, conditions such as asthma, diabetes, sickle cell disease, behavioral and neurological disorders, genetic syndromes. A comprehensive assessment assists the care manager in identifying needs, barriers and social determinants of health that assist the care manager in understanding the health and wellness of the newborn or child. The care manager collaborates with multiple providers, home health care, community agencies and the school system, when applicable, to aid in meeting specific physical, psychosocial and emotional needs of the developing child and family across the health care continuum.

Care Managers provide guidance on timely health screenings, annual well checks, immunizations, as well as refer members to health education classes and the health library to help members manage their health so they can stay as healthy as possible. Qualified health care professionals will provide assistance to help close gaps in care, which may include: annual wellness visits, screenings, monitoring labs to ensure therapeutic levels of a medication, earlier intervention, and engagement with a health care provider to proactively manage a potential health exacerbation based on clinical indicators (i.e. elevated blood pressure and HbA1c that are not within range).

Services include:

• Health maintenance and prevention reminders to promote self-management skills
• Health Education
• Recommendations on how to manage and maintain overall health and wellness

Care Managers provide members with assistance navigating the health care system following a health event, such as an emergency department (ED) visit, or recent inpatient hospitalization. Care Managers support members as they transition from the ED or hospital setting to the community (home) to help them better manage their health and reduce avoidable re-admissions.

Services include:

• Care Coordination including assisting with setting up appointments with providers
• Coordination of durable medical equipment and supplies
• Medication management and reconciliation
• Education to improve understanding of diagnoses
• Assistance with gaps in care

While care managers can provide this assistance to members assigned to them, the care managers on the clinical quality team provide this service to members that are not enrolled in one of the above care management service. This allows for assistance to be available population wide as needed.