Case Management Referral Form | 

Case Management

Hill Physicians makes it easy for our physicians to deliver quality patient outcomes.

Through our innovative Case Management program, we provide experienced RN case managers dedicated to working with physicians, patients and families to determine the best steps for each patient. This includes referrals to skilled nursing or specialized care facilities, community programs and more.

We provide coordination for a wide range of services to promote quality care outcomes that enhance the physical and psychological health of the individual, including:

• Coordinating and communicating with the healthcare team and family regarding care planning and implementation of recovery goals
• Short- and/or long-term care planning
• Assessing and coordinating the resources necessary to meet the patient's optimal care requirements
• Advising on the best use of healthcare benefits

Case Management Programs | Referral Resources | How to Make a Referral

Case Management Programs

We offer four case management programs.

Catastrophic/Complex Case Management

Our case managers help our physicians and other providers coordinate care for patients with complex medical conditions and/or treatment plans, including patients with:

• Chronic illnesses
• Catastrophic illness/injury
• Polypharmacy issues
• Multiple co-morbidities
• Breast cancer
• Organ transplants
• Complex socioeconomic issues
• Self-reported poor health

Predictive Modeling

Using a variety of patient diagnosis, lab and pharmacy data, our case managers are helping our physicians to identify patients who are at highest risk of developing complex chronic conditions. This, in turn, allows our physicians to provide the extra time, attention and care to patients with the highest need – intervening before a chronic condition develops or spirals out of control.

Welcome Home Program

In our Welcome Home Program, our case managers contact recently discharged hospital patients to ensure an effective discharge plan. Our focus is to help to minimize frequent hospitalization or emergency room use.

Bariatric Surgery Program

The Bariatric Surgery Program educates patients and helps them complete pre-surgery weight and exercise requirements.

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Referral Resources

Case Management provides referrals to:

• State or county agencies such as CCS, regional centers, IHSS and Medi-Cal Waiver Programs
• Hospice, home health or home infusion
• Support groups for chronic diseases, substance abuse, eating disorders and grief and bereavement
• Health education resources and select websites, for additional information
• Health plan chronic disease management programs
• Programs for CHF, DM, CAD, COPD, ESRD and others
• In-network providers

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How to Make a Referral

For more information, call (800) 445-5747, option 1.

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