Diana Salais

Providing complex case management for all PHP Capitated plans including Centennial Care delegation, for intervention with health conditions and complex psychosocial needs. Responsibilities include in depth comprehensive assessment within psychosocial, medical, behavioral environmental and financial parameters. Develop, document and implement a plan of care addressing emotional, physical, and complex social needs assuring quality of care. Provide care coordination to members with chronic, complex conditions requiring intensive clinical interventions, social and community resources. Coordinating care for members to achieve self-identified health goals and assure a positive member experience in collaboration with a care team. Advocating for member care needs by addressing gaps in care. Monitoring the care plan for effectiveness of interventions and documenting in patient electronic medical record in EPIC system. Assess Centennial Care members for Nursing Facility Level of Care for Medicaid Home & Community based services. Conduct home visits for PHP Centennial members per the contract with the State of NM.

Presbyterian and the New Mexico Retiree Health Care Authority (NMHRCA) partnered in a pilot to strategically utilize a Care Team of both a Pharmacist Clinician & Community Health Worker to assess its potential for bending the pharmacy costs curve while improving or maintaining patient health. CHW interventions included empowering patients to develop achievable health-related goals and provide support in achieving those goals. Roles and responsibilities included empowering patients burdened with managing chronic conditions. Facilitating patients understanding of their health conditions and comfort in communicating with providers. Supported patients in identifying and implementing lifestyle changes to decrease risk for progression of disease. Supported health literacy. Assisted patients in solving problems and overcoming barriers to self management of chronic illnesses.

Facilitated patients adjustment to the changes that come with dialysis. Assisted patients with becoming listed for kidney transplant services. Addressed and helped to remove barriers to becoming listed for transplant. Educated patients about kidney disease and their treatment options. Linking with community resources for transportation to dialysis, home health services and hospice care. Empowered patients to better understand kidney disease to make informed decisions about their care. Astute with federal Medicare, Medicaid and NMMIP insurance coverages for individuals with ESRD. Assist patients with getting and keeping insurance to cover cost of dialysis treatment.

Arrange for dialysis treatments at visiting clinics for patients needing to travel. Complete initial and annual psychosocial assessments comprehensive care plan. Participated in interdisciplinary rounds with physician. Responsible for documenting progress notes to comply with CMS requirements.

Conducted comprehensive health assessments for children, adolescents and adults in Centennial Care 1.0 Program. Development and implementation of a comprehensive care plan to meet State Centennial Care, NCQA and Molina Health Care standards. Secured medical care, behavioral health services and appropriate referrals for clients by working with community resources and contracted providers. Responsible for time-sensitive deadlines determined by State Centennial Care contract. Maintained Excel spreadsheet with time-lines of each member on case load. Developed workable solutions for recurring problems for individuals and families.