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Samaritan Select Disease Management Chronic Care Support Program.

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Presentation on theme: "Samaritan Select Disease Management Chronic Care Support Program."— Presentation transcript:

1 Samaritan Select Disease Management Chronic Care Support Program

2 Program Overview Based on Improving Chronic Illness Care (ICIC) - Chronic Care Model & Disease Management Association of America (DMAA) principles Utilizes: Interdisciplinary clinical teams Prevention guidelines Evidence-based practice guidelines Self-management goal setting Case management Continuous analysis of relevant data and cost-effective technology to improve health outcomes of members with specific diseases

3 Program Design Members automatically placed in Disease Management program upon identification “Opt-out” program (Members considered participating unless they request out) Disease Management program integrated with providers, case management and medication management

4 Specific Diseases Initial Diabetes Asthma CAD CHF Future Considerations Depression Hypertension Hyperlipidemia Obesity

5 Current Components 1. Health plan disease database 2. Evidence-based practice guidelines for specific diseases 3. Collaborative practice model with interdisciplinary clinical team 4. Patient self-management education 5. Process and outcomes measurement, evaluation and management 6. Routine reporting/feedback loop

6 Interdisciplinary Clinical Team Member PCP Health Plan: Case Management Nurses, Clinical Pharmacist Hospital: Case Management Nurses, Discharge Planners, Diabetic Educators, Respiratory Therapists, Cardiac Rehab Others as indicated

7 General Disease Management Identification Process

8 Once in the Disease Database Member placed into a specific level of case management determined by criteria Members contacted & followed periodically by case management nurses Care plan completed on each member placed in case management Case management nurse works closely with provider, member & other members of the interdisciplinary team Case loads compared periodically with disease database

9 Outcome Measurement and Evaluation Various types of reports reviewed on an ongoing basis. HEDIS Measures Member & Provider surveys Modifications made as necessary

10 Future Considerations 24/7 Nurse Triage Motivational Interviewing Predictive Modeling Pay for Performance Screening Clinics Regional Disease Registries Regional Education Program for Patients with Chronic Diseases Integrated Healthcare Delivery System

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