Disease management/population health
Disease management (DM) is based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing members with chronic conditions.
The mission of the DM program is to improve the health and quality of life for the members served by encouraging member self-care efforts, coordinating health care education and providing interventions along the continuum of care.
DM services include:
- A holistic, member-centric approach, focusing on the needs of the member through telephonic and field-based services.
- Motivational interviewing techniques used in conjunction with member self-empowerment.
- The ability to manage more than one disease to meet the changing health care needs of our member population.
- Weight management and smoking cessation education.
About DM programs under Simply Healthcare Plans, Inc.
We have programs for:
- Bipolar disorder.
- Coronary artery disease (CAD).
- Congestive heart failure (CHF).
- Chronic obstructive pulmonary disease (COPD).
- Major depressive disorder (MDD) in adults or children/adolescents.
- Substance use disorder (SUD).
Our programs feature:
- Proactive population identification processes.
- Evidence-based national practice guidelines.
- Collaborative practice models to include physician and support-service providers in treatment planning for members.
- Continuous patient self-management education including primary prevention, coaching related to healthy behaviors, and compliance/monitoring and case/care management for high-risk members.
- Ongoing communication with primary and ancillary providers regarding patient status.
- NCQA accreditation for nine of our programs, which incorporate outreach, education, care coordination, and follow-up to improve treatment compliance and enhance self-care.
DM programs are designed to:
- Address gaps in care.
- Improve the understanding of disease processes.
- Improve the quality of life for our members.
- Support collaboration to develop member-centered goals and interventions.
- Support relationships between the member and network providers.
- Increase network provider awareness of DM programs.
- Reduce acute episodes requiring emergent or inpatient care.
- Identify and address barriers to health care by referring members to appropriate community resources.
Who is eligible?
Members diagnosed with one or more of the above conditions are eligible for DM services.
What are the benefits of collaborating with DM?
- Maximize your time — if you have patients with one or more of the conditions listed above, who could benefit from additional education or care management, we encourage you to refer them to DM.
- Collaborative treatment plans — DM invites your input for patient treatment plans. We provide you with DM information and the most up to date Clinical Practice Guidelines (CPG) to assist you in creating an individual plan of care.
- CPGs are available on the secure provider website (login is required). CPGs can also be requested at any time.
- Receive feedback on your patients between appointments — you can access Patient360 to obtain feedback on your members regarding their care plans and condition management while enrolled in DM.
How can I refer a member to DM?
To refer a member, fax a completed
Disease Management Referral Form
What if I need assistance?
Hours of Operation
DM case managers are registered nurses and are available from 8:30 a.m. to 5:30 p.m. local time, Monday through Friday. Confidential voicemail is available 24 hours a day. The 24/7 NurseLine is available 24 hours a day, 7 days a week for our members.
You can call 1-888-830-4300 to reach a DM case manager. Your patients can get information about DM program services by visiting our member website or calling 1-888-830-4300.
Provider rights and responsibilities
You have additional rights and responsibilities including the right to:
- Obtain information about the organization’s services, staff qualifications and any contractual relations.
- Decline to participate in or work with the organization’s programs and services on behalf of their patients.
- Be informed on how the organization coordinates interventions with care plans for individual members.
- Know how to contact the case manager responsible for managing and communicating with your patients.
- Be supported by the organization when interacting with members to make decisions about their health care.
- Receive courteous and respectful treatment from the organization’s staff.
- Communicate complaints to the organization.
These rights and responsibilities are available to you in written format upon request to DM by calling 1-888-830-4300.