Disease Management Program

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Community Health Plan has determined three chronic care programs that are relevant and address the needs of its enrollee population. The programs are diabetes and asthma for all enrollees, with the addition of hypertension for Medicare enrollees.

Disease management components include:

  • Population identification processes
  • Evidence-based practice guidelines
  • Collaborative practice models to include physician and support-service providers
  • Patient self-management education (may include primary prevention, behavior modification program, and compliance/surveillance)
  • Process and outcomes measurement, evaluation, and management

The Community Health Plan Disease Management program works with a practitioner’s patient in several ways. This includes the following actions:

  • Promote disease specific education through productive interactions with enrollees.
  • Coordinate with practitioners to assure the delivery of key clinical and behavioral elements of care.
  • Identify high risk, high cost enrollees with diabetes and/or asthma with complex medical and/or psychosocial needs to assess treatment options and opportunities for improved outcomes.

Disease Management Program

The programs use third-party risk-stratification programs to identify enrollees who qualify for DM programs by using the following data sources:

  • Claims or encounter data
  • Pharmacy data if applicable
  • Health risk appraisal results
  • Laboratory results if applicable
  • Data collected through the care management or case management process if applicable
  • Enrollee and practitioner referral

All newly identified enrollees are automatically enrolled in the program.

The objectives for the Disease Management programs include the following:

  • Improve the ability of enrollees to self-manage their disease through the provision of relevant information, tools, and training.
  • Increase enrollees’ knowledge of their condition and treatment options and delay further progression and related complications.
  • Improve health outcomes and compliance with disease-specific evidence-based guidelines.
  • Enhance quality of life by encouraging and empowering enrollees with self- management.
  • Optimize how enrollees use health care.
  • Assist enrollees in accessing care and test results, and achieving recommended levels of control.

The enrollees are systematically identified monthly for each of the programs: low acuity (level I), moderate acuity (level II), and high acuity (level III). See sections below for definition and interventions relating to each acuity level.

All enrollees identified will receive a welcome letter to the Disease Management program and semiannual DM educational materials. Enrollees will receive other education materials based on their need, acuity level, individual care plan, and consultation with PCP.

Community Health Plan provides eligible enrollees with written program information regarding:

  • How to use the DM services
  • How enrollees become eligible to participate in the programs
  • How to opt in or out of the programs

Additionally, educational materials are available to all enrollees. See the disease management guidelines.

Low acuity, level I:

These enrollees have, for example, mild to moderate asthma or well controlled diabetes. They are connected to their PCP, who coordinates their care, and are informed and active in the management of their condition. They are connected to their community resources.

Intervention: They will receive semi-annual disease-specific educational information.

Moderate acuity, level II:

These enrollees with a chronic condition would benefit from disease, medication, or safety education. They may have comorbid conditions. Their connection to their PCP or community resources may be fragmented. There may be cultural, language, psychosocial, or transportation barriers to care. There is some medical plan of care or medication nonadherence concern.

Intervention:

  • Follow-up letter generated to PCP post Health Risk Assessment (HRA).
  • Patient clinical needs-specific education materials sent.
  • Referral as necessary by DM team to community resources.
  • If indicated, the enrollee is referred to plan level case management services.

High acuity, level III:

The HRA DM psychosocial assessment data confirms these enrollees have a severe and/or deteriorating chronic condition, multiple comorbidities, complex care needs, and multiple medications.

They may require DME and/or custodial care. They may be poorly connected to their PCP and specialists, who may not be collaborating on a care plan. There are cultural, language, psychosocial, or transportation barriers to obtaining services. Community resources have not been accessed. ER use may be high and hospitalizations may be frequent. Care plan and medication nonadherence may be present and could be life threatening.

Intervention:

  • Follow-up letter generated to PCP post HRA.
  • Summary of findings and recommendations is created and sent to the PCP.
  • Patient-specific clinical education materials sent.
  • Community resources referral and entitlement assessment.
  • If indicated, the enrollee is referred to plan level case management services.

Disease Management Referral Process

Enrollees can be referred to Community Health Plan Disease Management by faxing the referral form to 206-652-7073.