Our in-house medical team of doctors, pharmacists and nurses provide wellness and preventive services for healthy customers and Disease Management programs for those who experience chronic illness. (These programs may not apply to all policyholders.)
| UTILIZATION REVIEW
Our comprehensive approach ensures that members receive necessary care without unnecessary exposure to risks when applicable. We use evidence-based clinical criteria to reduce unjustified variation in care, which:
- Decreases differences
- Reduces gaps in knowledge
- Improves quality
- Supports evidence-based decision making
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CLINICAL ROUNDS
A team of physicians and nurses actively participate and consult with a social worker and pharmacist when applicable to:
- Highlight areas for care coordination improvement
- Identify opportunities for quality and case management
- Assist knowledge and information exchange
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| CASE MANAGEMENT
Through our case management program, we assess, plan and assist with options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes. We help by:
- Resolving barriers to achieve most favorable outcome
- Assisting with coordination of complex treatment plans
- Screening members for behavioral health issues
- Addressing medical necessity issues
- Supporting the member with the healthcare team
- Providing health information to members for informed decision-making
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DISEASE MANAGEMENT
This program coordinates healthcare interventions and communications for a population with conditions in which patient self-care efforts are significant. The program manages today for a healthy tomorrow by:
- Providing coaching to improve health outcomes and promote healthy lifestyles
- Emphasizing prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies
- Supporting member values and preferences
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Key Differences Between Case Management and Disease Management
- Case Management focuses on one individual to maximize health outcome - its duration is usually shorter and associated with a single episode of illness
- Disease Management tries to improve the health of an entire population with a certain condition - participation lasts two years or longer to make lifestyle changes and then sustain the change over time
Contact Information
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Case Management and Disease Management |
1.800.317.2299 |
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