Disease Management

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

Members are identified by:

• ICD-9 codes
• Ancillary data, including laboratory studies with specific lab values
• Medication history
• Hospitalizations
• Health Plan Employer Data and Information (HEDIS)
• Physician Profile

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.

Download Literature:

• Asthma

Care1st and ONECare have adopted the National Asthma Education and Prevention Program (NAEPP) Guidelines for Diagnosis and Management of Asthma. The new version became available in 2007.  A summary report of the guidelines can be found at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

A table outlining the changes made to the document was posted in August 2008 and can be found at:
http://www.nhlbi.nih.gov/guidelines/asthma/epr3-errata.htm

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• Chronic Heart Failure

Care1st and ONECare have adopted the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.  It was developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation.  A summary report of the guidelines can be found at:
http://content.onlinejacc.org/cgi/reprint/46/6/1116.pdf

The American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation a 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. The report can be found at:
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192064

With the exception of the recommendations presented in this report, the full guideline remains current.

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• Diabetes

Care1st and ONECare have adopted the American Diabetes Association Standards of Medical Care in Diabetes – 2011.  The executive summary report can be found at:
http://care.diabetesjournals.org/content/34/Supplement_1/S4.full.pdf+html

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Practice and Preventive Health Guidelines | Prior Authorization Guidelines & Criteria