Disease Management

Disease Management

Our Disease Management approach includes:

  • Identification and stratification of Members using our predictive risk modeling (PRM) system;
  • Use of a comprehensive health risk assessment (HRA) process and new Member welcome calls to identify Member health needs;
  • Implementation of an individualized plan of care tailored to address each Member’s physical and behavioral health needs;
  • Documentation of each Member’s care plan using a single Member-centric system, CareAdvance®;
  • Use of nationally-recognized, evidence-based clinical practice guidelines for treatment and identification of gaps in care;
  • Effective, timely, and consistent Member outreach and education activities;
  • Facilitated and encouraged Provider participation;
  • Coordination with Case Management to maximize Care Management value; and
  • Program evaluation initiatives focused on continuous quality improvement.

Disease Management’s mission is to provide a fully integrated health solution that encompasses a multi-faceted approach to educate, coach, support, and empower individuals to assume responsibility for their own health status, for resolving knowledge gaps, and to take action in improving their quality of life and health outcomes.

Our DM program emphasizes education in order to incorporate self-management strategies, promote regular Practitioner follow-up, and increase Member understanding of his/her condition.  Disease Management goals include the following:

  • Increase Member adherence to the treatment plan through education about:
  • Basic pathophysiology of their condition;
  • Current treatment modalities with emphasis on acute and continuation phases of treatment;
  • Self-monitoring and self-management techniques;
  • Appropriate use of medication and services;
  • Nutrition and exercise;
  • Importance of keeping regularly scheduled provider appointments;
  • Recognizing and addressing psychosocial issues related to their condition; and
  • Complications and preventive care.
  • Improve physical and mental functional status;
  • Improve Provider adherence to the guidelines through identification and resolution of gaps in care;
  • Improve HEDIS® rates;
  • Decrease inpatient admissions and emergency room visits;
  • Facilitate and encourage Provider participation;
  • Coordination with Case Management to maximize care management value; and
  • Program evaluation initiatives focused on continuous quality improvement.

Early detection – You can help

It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

At Volunteer State Health Plan, Inc. we remain committed to working with our Providers to ensure quality service to our Members. It is our intent to make resources available to our Providers that will help in this endeavor.

Provider participation and adherence to Volunteer State Health Plan adopted Clinical Practice Guidelines (CPGs) is important to the overall success of the DM programs. Providers can access these CPGs in the BCBST Healthcare Practice Recommendations Manual located on the company website at http://www.bcbst.com/providers/hcpr/.

Disease Management Programs

Disease Management Interventions

 

Page Modified:May 21, 2012