Disease Management
Disease Management Program Overview
Care1st provides a Disease Management program to assist health professionals and providers in managing members diagnosed with targeted chronic illnesses. When not managed through coordinated strategies, these conditions frequently result in hospitalizations and/or medical complications that require greater utilization of resources and higher costs.
The chronic diseases Care 1st is focusing on are:
- Diabetes
- CHF
- Asthma
- COPD
Members are identified by:
- Ancillary data, including laboratory studies with specific lab values
- Utilization data-Hospitalization, Medication history
- Health Plan Employer Data and Information (HEDIS)
- Member Health Risk Assessment and EPSDT forms
- Provider referrals and referrals from other sources
The disease management process is as follows:
- The disease management nurse makes initial contact with identified member via telephone and completes a comprehensive initial assessment.
- The disease management nurse determines from the assessment if the member is placed into the program. Areas considered for enrollment are:
- Elevated lab values
- Need for education
- Need for follow-up with primary care physician
- Need for specialist referrals
- Need for equipment
- Interventions utilized to manage members enrolled in the program are as follows:
- Educating members about the disease, its symptoms and effective tools for self-management
- Assisting members with enrollment in existing education classes if available
- Educating members on medications
- Assisting members with appointments with primary care physician
- Assisting members with referrals to specialists
- Assisting members in obtaining equipment covered under the plan
- Members in the program will be followed at 1, 3, and 6 month intervals or more frequently to monitor effectiveness of interventions.
Practice Guidelines
- Asthma
- Chronic Heart Failure
- ADA Summary of Revisions to the 2016 Clinical Practice Recommendations
- COPD GOLD Guidelines (2016 Update)
Practice and Preventive Health Guidelines | Prior Authorization Guidelines & Criteria
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