Disease Management/​Population Health
Our Disease Management (DM)/Population Health Program (PHP) is based on a system of coordinated care management interventions and communications designed to help physicians and other health care professionals manage members with chronic conditions.
Mission
The mission of Disease Management/Population Health is to improve the health and quality of life for the members we serve. We do this by encouraging self-care efforts, coordinating health care education and providing interventions along the continuum of care.
DM/PHP services include:
- A holistic, member-centric approach to disease management focusing on the needs of the member through telephonic and community-based resources.
- Motivational interviewing techniques used in conjunction with member self-empowerment.
- The ability to manage more than one disease to meet the changing health care needs of our member population.
- Weight management and smoking cessation education.
DM/PHP programs include:
- Asthma
- Bipolar disorder
- Coronary artery disease (CAD)
- Congestive heart failure (CHF)
- Chronic obstructive pulmonary disease (COPD)
- Diabetes
- HIV/AIDS
- Hypertension
- Major depressive disorder (MDD) — adults
- Major depressive disorder (MDD) — children/adolescents
- Schizophrenia
- Substance use disorder (SUD)
Who is eligible for DM/PHP?
Members diagnosed with the above conditions as identified through continuous case finding efforts, claims data and referrals are eligible for Disease Management/Population Health Program services.
How can I refer a member to DM/PHP?
To refer a member, fax a completed Disease Management/Population Health referral form to 1-888-762-3199
What are some of the DM/PHP features?
- Proactive population identification processes.
- Evidence-based national practice guidelines.
- Collaborative practice models to include physician and support service providers in treatment planning for members.
- Continuous patient self-management education, including primary prevention, coaching related by healthy behaviors modification programs and compliance or monitoring, and case management for high-risk members.
- Ongoing communication with primary and ancillary providers regarding patient status.
- NCQA accreditation for nine of our programs, which incorporate outreach, education, care coordination and follow-up to improve treatment compliance and enhance self-care.
What are DM/PHP programs designed to do?
- Address gaps in care.
- Improve member understanding of disease processes.
- Improve the quality of life for members.
- Collaborate with providers to develop member-centered goals and interventions.
- Support relationships between the member and provider networks.
- Increase network provider awareness of DM/PHP.
- Reduce acute episodes requiring emergent or inpatient care.
- Identify social determinants of health and address them by referring members to appropriate community resources.
What are the benefits of collaborating with DM/PHP?
Quality of care
If you have patients with one or more of the conditions listed above who could benefit from additional education or care management, we encourage you to refer them to DM/PHP.
Collaborative treatment plans
DM/PHP invites your input for patient treatment plans. We provide you with DM/PHP information and the most up-to-date Clinical Practice Guidelines (CPGs) to assist in creating an individual plan of care for your patient.
- CPGs are available on Availity (login is required).
Receive feedback on your patients between appointments
You can access Patient360 to obtain feedback on your patients regarding their care plans and condition management while enrolled in DM.
How to contact Disease Management/Population Health
Call 1-888-830-4300 to reach a case manager between 8:30 a.m. and 5:30 p.m. local time, Monday to Friday. Confidential voicemail is available.
Members can get information about DM services by calling the number above or visiting our member website.
The Nurse Helpline is available to members 24/7 at 1-866-864-2544.
Provider rights and responsibilities
You have additional rights and responsibilities, such as the right to:
- Obtain information about the organization’s services, staff qualifications and any contractual relations.
- Decline to participate in or work with the organization’s programs and services on behalf of their patients.
- Be informed how the organization coordinates interventions with care plans for individual members.
- Know how to contact the case manager responsible for managing and communicating with their patients.
- Be supported by the organization when interacting with members to make decisions about their health care.
- Receive courteous and respectful treatment from the organization’s staff.
- Communicate complaints to the organization.
The Clinical Practice Guidelines (CPGs) for the chronic conditions outlined above are available on Availity, our secure provider website. CPGs can be requested at any time.
Our disease management/population health programs do not advertise, market or promote specific products or services to members or providers. We do not have financial ownership arrangements with anyone who advertises, markets or provides the goods and services we offer.