A Unique Integrated Model
Lifestyle Health Coaching
Due to the nature of the population, all members identified for chronic condition management are to be managed in a holistic approach: setting goals and expectations at an individual level.
Chronic condition management staff will develop care plans to encompass multiple conditions as opposed to placing members in condition-specific programs only.
Lifestyle Health Coaching conditions include:
– Allergies
– Nutrition
– Hyperlipidemia
– Osteoporosis History and Risk
– Physical Inactivity
– Smoker
– Stress
– Urinary Incontinence
Care Coordination Program conditions include:
– Alzheimer’s Disease
– Atrial Fibrillation
– Cancer
– Coronary Artery Disease Risk
– Diabetes Risk
– Emergency Services
– Fall Risk
– Fibromyalgia
– Hepatitis C
– Hypertension
– Low Back Pain
– Obesity
– Stroke (CVA)
Care Coordination Program Management Tools & Methods:
– Referrals: Registry, Tracking & Management
– Lab Result Tracking
– Medication Therapy Management (MTM):
• Interaction Alerts
• Adherence Coordination
• Allergy Alerts
• Preventive Medicine Reminders
– Pre-Certifications
– Authorizations
– Clinical Informatics
• Evidence-based Reminders
• Decision Support
• Practice Pattern Analysis & Remediation
Chronic Condition Management Programs conditions include:
– Diabetes
– Congestive Heart Failure (CHF)
– Asthma
– Coronary Artery Disease (CAD)
– Chronic Obstructive Pulmonary Disease (COPD)
– Maternity Management
– Obesity
Catastrophic Case Management Program conditions include:
– AIDS/HIV
– End Stage Disease (any organ)
– Burns
– Cerebral Palsy
– Chronic cases that could benefit from CM
– Complex Home Care
– Continuous IV infusion of Epoprosternol Sodium (for treatment of Pulmonary Hypertension)
– Crohn’s Disease
– Cystic Fibrosis
– Frequent Inpatient Admissions
– Hemochromatosis
– Hemophilia or allied bleeding disorders
– High claims cost
– Lupus (Dermatomytosis)
– Multiple chronic conditions
– Neurological conditions
– Renal failure (acute or chronic)
– Rheumatoid Arthritis
– Skilled Nursing Visits > 2 per day for 30 day duration
– Spinal Cord Injury
– Traumatic Brain Injury
– Ulcerative Colitis
– Ventilator Dependency
Behavioral Health Case Management Program conditions include:
– Alcohol or drug abuse
– Depression
– Mental illness
– Bipolar
– Schizophrenia
✓ Individualized care plans to assist high risk members with multiple medical and behavioral health co-morbidities.
✓ Home & Community-based Services enhances the ability to reach, engage, educate and motivate members/patients who typically are the most difficult to manage.
Transplant Case Management Program conditions include:
– Single solid organ
– Bone marrow/stem cell
– Multiple organ
End of Life Management Program conditions include:
– End stage disease
– Advance directives
– Palliative/hospice care
– Caregiver needs
