First step is that the member must be eligible for Medicaid with one of the following aid categories:
• Aged
• Blind
• Disabled Physically and mentally disabled
• Wards of the court and foster children
• Children receiving adoptive services
Second, a member must also have one of the following conditions:
• Asthma
• Diabetes
• Congestive Heart Failure (CHF) or Coronary Artery Disease (CAD)
• Hypertension
• Chronic Kidney Disease without dialysis
• Rheumatic Heart Illness
• Severe Mental Illness (SMI)
• Serious Emotional Disturbance (SED)
• Depression
The member must also be selected by Medicaid and choose to enroll.
7.3 Types of Disease Management
The objectives of Disease Management programs are to:
• Identify Members that would benefit from the specific disease management program
• Educate Members on their disease, symptoms and effective tools for self‐
management
• Monitor Members to encourage/educate about self care, identify complications, assist in coordinating treatments and medications, and encourage continuity and comprehensive care
• Provide evidence‐based, nationality recognized expert resources for both the Member and the provider
• Monitor effectiveness of interventions
Asthma
The Asthma Disease Management program offers coordination of care for identified Members with primary medical providers, specialist, community agencies, the Members’ caregivers and/or family. Member education and intervention is targeted to empower and enable compliance with the physician’s treatment plan. Providers play an
important role in helping Members manage this chronic disease by promoting program goals and strategies, including:
• Preventing chronic symptoms
• Maintaining “normal” pulmonary function
• Maintaining normal activity levels
• Maintaining appropriate medication ratios
• Preventing recurrent exacerbation and minimizing the need for emergency treatment or hospitalizations
• Providing optimal pharmacotherapy without adverse effects
• Providing education to help Members and their families better understand the disease and its prevention/treatment
ADVANTAGE Care Select Program has adopted Asthma Outpatient Practice Guidelines from the American Lung Association that are reviewed annually. These guidelines may be viewed on the ADVANTAGE Web site at www.advantageplan.com.
Congestive Heart Failure (CHF) and Rheumatic Heart Illness
The CHF and Rheumatic Heart Disease Management program is designed to develop a partnership between the ADVANTAGE Care Select Program, the primary care provider and the Member to improve self‐management of the disease. The program involves identification of Members with CHF and Rheumatic Heart Illness and engages them in subsequent targeted education and interventions.
The objectives of the CHF and Rheumatic Heart Disease Management Program are to:
• Educate Members with CHF or Rheumatic Heart Illness on their disease process
• Educate members on the following:
o Cardiac symptoms
o Emotional/Psychological aspects of the CHF or Rheumatic Heart illness
o Blood pressure management o Weight management
o Nutritional requirements o Smoking cessation
The ADVANTAGE Care Select Program has adopted CHF guidelines from ACC/AHA that are reviewed annually. These guidelines may be viewed on the ADVANTAGE Web site at www.advantageplan.com.
Diabetes
The Diabetes Disease Management program is designed to develop a partnership between the ADVANTAGE Care Select Program, the primary medical provider and the Member to improve self‐management of the disease. The program involves identification of Members with diabetes and subsequent targeted education and interventions. In addition, the program offers providers assistance in increasing Member compliance with diabetes care and self‐management regimens.
Providers play an important role in helping Members manage this chronic condition.
ADVANTAGE Care Select appreciates providers’ efforts in promoting the following program goals and strategies:
• Referrals for formal diabetes education through available community programs
• Referrals for annual diabetic retinal eye exams by eye care professionals as defined in ADVANTAGE Care Select Program’s Diabetes Management Practice Guidelines
• Laboratory exams that include:
o Glycohemoglobins at least twice annually o Micro albumin
o Fasting Lipid profile annually
• Management of co‐morbid conditions like blood pressure, CHF, and blood cholesterol.
ADVANTAGE Care Select Program has adopted Hypertensive Heart Disease Outpatient Practice Guidelines from the ACC/AHA that are reviewed annually. These guidelines may be viewed on the ADVANTAGE Web site at www.advantageplan.com.
Chronic Kidney Disease (CKD) or Hypertensive Heart and Kidney Disease
The Chronic Kidney Disease program is designed to develop a partnership between the ADVANTAGE Care Select Program, the primary medical provider and the Member to improve self‐management of the disease. The program involves identification of members with Chronic Kidney Disease and subsequent targeted education and interventions. In addition, the program offers providers assistance in increasing Member compliance with Chronic Kidney Disease care and self‐management tools to monitor their condition.
Providers play an important role in helping Members manage this chronic condition.
ADVANTAGE Care Select appreciates providers’ efforts in promoting the following program goals and strategies:
• Educate Members on the following:
o Emotional/Psychological aspects of Kidney disease o Blood Pressure management
o Weight management o Nutritional requirements o Smoking cessation
o When to seek medical care
• Work with the doctor to perform lab tests to check and monitor kidney functioning:
o Glomerular Filtration Rate (GFR) o Micro albumin
o Additional physician recommended testing
• Promote appropriate dietary management
• Identify medications to avoid such as over‐the‐counter remedies
The ADVANTAGE Care Select Program has adopted the KDOQI Clinical Practice Guidelines for Chronic Kidney Disease from the National Kidney Foundation that are reviewed annually. Please refer to the ADVANTAGE Web site at www.advantageplan.com for further information.
Behavioral Health Disease Management Conditions
The Behavioral Health Disease Management Program contains the following conditions:
• Depression
• Severe Mental Illness Management (SMI)
• Serious Emotional Disturbance (SED)
The programs are all designed to develop a partnership between the ADVANTAGE Care Select Program, the primary care provider and/or the behavioral health provider and the Member to improve self‐management of the disease. The program involves identification of Members with certain behavioral health conditions that will receive education and interventions for their behavioral health conditions.
The objectives of the Behavioral Health Disease Management Programs are to:
• Educate Members with behavioral health conditions on their disease process
• Educate members on the following:
o Provide disease‐specific education to the member and caregiver or family
o Connect member to community resources
o Educate the member on self‐referral services for behavioral health treatment
o Enhance continuity of care as evidenced by medication and behavioral health appointment adherence
o Promote awareness of stressors and regular patterns of activity and sleep
o Work with the patient to anticipate and address early signs of relapse
• Management of co‐morbid conditions like Asthma, Diabetes, CHF, Hypertensive Heart Disease, Hypertensive Heart and Kidney Disease, and other behavioral health conditions.
The ADVANTAGE Care Select Program has adopted Depression Guidelines, Bipolar Disorder Guidelines, Schizophrenia Disorder Guidelines, and Major Depression Guidelines from the Department of Health and Human Services, American Psychiatric Association, and the Academy of Child and Adolescent Psychiatry that are reviewed annually. Please refer to the ADVANTAGE Care Select Program web site at www.advantageplan.com for further information.