Disease Management Be In Charge Program

The Disease Management - Be In Charge!^SM program provides disease-specific management for members with asthma, diabetes and heart failure (HF). The goal of the program is to:

• Improve member knowledge and self-management of these diseases leading to improved quality of life, better functional status and reduced disease complications.
• Enhance the effectiveness of care provided to members by:
  • Improving physician knowledge of their assigned members with the identified diagnosis.
  • Improving physician and member compliance with evidence-based screening and treatment guidelines.
  • Improving member compliance with evidence-based screening and treatment guidelines through targeted annual mailings, telephonic coaching and interactive voice response (IVR) reminder calls.
• Decrease preventable hospitalization and inappropriate emergency room utilization.
• Ensure that Health Net's interventions support and extend, but do not duplicate, participating physician groups' (PPGs') disease management programs.
• Ensure quality enhancement for members by providing a National Committee for Quality Assurance (NCQA)-certifiable program.
• Meet the contractual requirements as defined by the Health Net contract with the Department of Health Care Services.

Health Net has a business relationship with AxisPoint Health (McKesson Health Solutions) to provide all disease management functions for the Disease Management - Be In Charge! program. AxisPoint Health is a NCQA-certified vendor of disease management services.

Health Net's Disease Management - Be In Charge! program follows the NCQA best practice four step model of population identification, stratification, education, and intensive coaching for high-risk members.

Identification and Stratification

Eligible members are identified monthly based on review and analysis of claims, encounter, pharmacy, and eligibility data in compliance with the NCQA specifications for disease management.

Members meeting identification criteria receive a composite risk score and are stratified quarterly into three risk levels (red, yellow and green). Members in all three categories receive mailings and calls as specified:

• Green category - Low risk (RL1): initial welcome mailing with IVR call, and two educational IVR calls and two direct mail educational pieces annually.
• Yellow category - Moderate risk (RL2): Green category outreach activities, plus outbound calls from a registered nurse (RN) in accordance with the Moderate-Risk Medicaid call schedule.
• Red category - High risk (RL3): Green category outreach activities, plus outbound calls from an RN in accordance with the High-Risk Medicaid call schedule.

Materials are tailored to the diverse clinical, cultural and linguistic needs of Medi-Cal members.

Member and Practitioner Outreach and Resources

Health Net mails educational materials, an action plan, information about the program, and contact numbers for the Health Net Nurse Advice Line and disease management program to members enrolled in the Disease Management - Be In Charge! program. Health Net conducts outbound telephonic interventions and referrals to complex case management for members identified as being at high risk for hospitalizations or poor outcomes. Members also have access to the Health Net Health Education Department. Providers can also refer a member for complex case management by using the Care Management Referral Fax Form – Medi-Cal (PDF), Care Management Referral Fax Form – Community Health Plan of Imperial Valley (PDF) or Care Management Referral Fax Form – CalViva Health (PDF) members.

Twice a year, Health Net sends primary care physicians (PCPs) lists of their Health Net, Community Health Plan of Imperial Valley or CalViva Health members enrolled in the disease management program and each member's risk category following identification and stratification activities.

Providers should contact the Health Net Health Education Department when referring members who have asthma, diabetes or heart failure, and are not currently in the program. Members may also self-refer into the program or may opt out of this program at any time by contacting the Health Education Department.

Coordination with California Children's Services

For Medi-Cal members with diabetes under age 21, all related diabetes care, including medications and case management services, is arranged by California Children's Services (CCS). Health Net's health assessment coordinators and utilization management nursing staff work with providers and members to make sure that appropriate CCS referrals are made for all type 1 and type 2 diabetic members. CCS has its own network of providers. To access case management services and obtain authorization for services, providers must submit a Service Authorization Request (SAR) to the county CCS program. Diabetic members under age 21 are not included in Health Net's disease management program.

Coordination with California Children's Services

Medi-Cal members under age 21 with a chronic pulmonary condition that causes significant reduction of lung volume or anatomical morphology, such as bilateral pulmonary dysplasia, receive care arranged by CCS. The care includes medications and case management services through CCS' network of providers. Members with asthma under age five are not included in the Disease Management - Be In Charge! program.