Disease Management

Disease Management Guidelines

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:

  1. The disease management nurse makes initial contact with identified member via telephone and completes a comprehensive initial assessment.
  2. The disease management nurse determines from the assessment if the member is placed into the program. Areas considered for enrollment are:
    1. Elevated lab values
    2. Need for education
    3. Need for follow-up with primary care physician
    4. Need for specialist referrals
    5. Need for equipment
  3. Interventions utilized to manage members enrolled in the program are as follows:
    1. Educating members about the disease, its symptoms and effective tools for self-management
    2. Assisting members with enrollment in existing education classes if available
    3. Educating members on medications
    4. Assisting members with appointments with primary care physician
    5. Assisting members with referrals to specialists
    6. Assisting members in obtaining equipment covered under the plan
  4. Members in the program will be followed at 1, 3, and 6 month intervals or more frequently to monitor effectiveness of interventions.

Practice Guidelines

Practice and Preventive Health Guidelines | Prior Authorization Guidelines & Criteria