Samaritan Select Disease Management Chronic Care Support Program

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

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

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

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

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

General Disease Management Identification Process

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

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

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