Population Health’s Disease Management Program
Disease Management (DM) in Tennessee is part of our comprehensive Population Health program.
All Amerigroup Community Care members with diagnoses of the conditions below are eligible. Please refer patients who can benefit from additional education and care management support.
- Bipolar disorder
- Coronary artery disease (CAD)
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure (CHF)
- Major depressive disorder — adult and child/adolescent
- Smoking cessation
- Substance use disorder
- Weight management
How can I refer a member to Population Health’s Disease Management (PHDM)?
Fill out and email to DM-PHP-Provider-Referrals@amerigroup.com or access the form via Availity.
Population Health’s Disease Management programs
These programs are based on a system of coordinated care management interventions and communications designed to help you and other health care professionals manage members with chronic conditions. Services include a holistic, member-centric care management approach that allows case managers to focus on multiple needs of members. Motivational interviewing techniques are used in conjunction with member self-empowerment.
Members can access quarterly newsletters online to learn about their health plan benefits, special programs they may qualify for, medical news and more.
Eligible members receive:
- Education materials emphasizing self-management strategies for healthy behaviors like accessing health care services, maintaining collaborative relationships with providers, maintaining a healthy weight, being tobacco-free and self-monitoring
- Introductory packages upon enrollment in the program that provide information about availability of nurse coaching
- Offers a continuum of targeted intervention — education and enhanced access to services intended to encourage member self-management.
- Supports members through screenings, assessments and tailored interventions.
- Sends eligible members condition-specific education materials addressing:
- Information about their primary diagnoses.
- Self-management strategies.
- Medication adherence.
- Coordination of services.
By using these tools and working with a case manager, the member’s behavioral, social and physical health care needs are addressed.
Once identified from enrollment as pregnant, members are stratified as low-, medium-, high- or urgent-risk OB based on responses to screeners and are provided varying levels of support based on clinical risk factors.
All identified pregnant members, regardless of stratification level, have access to prenatal and postpartum educational materials, as well as information about incentives, to encourage mothers to make and keep prenatal and postpartum appointments. All pregnant members have access to Amerigroup on Call, our 24/7 Nurse HelpLine. We track and report Taking Care of Baby and Me® mailings, as well as members’ utilization of incentives.
Members enrolled in any Population Health Disease Management program are also eligible at any time for care coordination. Members may benefit from care coordination services when they have short-term, immediate, targeted needs and do not require complex case management services. Additionally, members with more intensive needs appropriate for complex case management who refuse those services may be appropriate for care coordination services.
Members may receive various interventions, including:
- Assistance with resources like transportation and pharmacy benefits.
- Arranging PCP appointments.
- Telephonic contact for coaching.
- Mailings of disease-specific education materials.
- Information regarding Amerigroup-on-Call (physicians available 24 hours a day, 7 days a week for consultation and advice).
We administer an initial health risk assessment to members identified for the Complex Case Management program. The case manager assesses the member’s total health care needs in a holistic manner, including physical, behavioral, functional, cognitive and social factors — This includes a gap analysis to determine health care needs and prioritize goals. Once needs are identified, the case manager works with the member and health care provider(s), family and caregiver(s) to develop interventions to achieve identified goals.
Examples of interventions include:
- Health education.
- Interpretation of benefits.
- Community resource referrals.
- Post-discharge service authorizations and member outreach (for example, DME, home health services and coordination of physician appointments).
- Service coordination.
- Medication reconciliation review.
- Assistance to develop a self-management plan.
- Community-based services (for example, home or hospital visits).
- Provider-based intensive case management (behavioral health).
- Special needs program interventions.
- Ongoing assessment of barriers to meeting goals or complying with the care plan and interventions to address those barriers.
How the program works
Our case managers obtain your input in the development of care plans. Members identified for participation are assessed and risk stratified based on the severity of their diseases. Once enrolled in a program, they are provided with continuous education on self-management concepts like primary prevention, behavior modification and compliance/monitoring, as well as case/care management for high-risk members.
Providers can access Patient360 to obtain feedback on their members regarding their care plans and condition management while enrolled in Population Health’s Disease Management program.
Program features include:
- Proactive population identification.
- Evidence-based national practice guidelines.
- Collaborative practice models include physician and support-service providers in treatment planning for members.
- Continuous patient self-management education, (including primary prevention, coaching healthy behaviors and compliance/monitoring) case/care 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.
Program objectives are to:
- Address gaps in care.
- Improve the understanding of disease processes.
- Improve the quality of life for our members.
- Provide opportunities for patient-centered care.
- Support network provider relationships with members.
- Support relationships between the member and network providers.
- Increase network provider awareness of disease management programs.
- 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 PHDM?
- Maximize your time — 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.
- Collaborative treatment plans — PHDM invites your input for patient treatment plans. We provide you with DM information and the most up-to-date Clinical Practice Guidelines (CPGs) to assist you in creating an individual plan of care.
- CPGs are available on the secure provider website (login is required). CPGs can also be requested at any time.
- Receive feedback on your patients between appointments — You can access Patient360 to obtain feedback on your members regarding their care plans and condition management while enrolled in DM.
All of our programs are based on nationally approved clinical practice guidelines available in the Manuals and Guides portion of this site. You can print online or call our Provider Services team at 1-800-454-3730 to request a copy.
Provider Services team