The goals of the program are to:

*Adult programs only.

** Pediatric weight management program is ages 2 years and above; tobacco cessation programs are ages 12 years and above.

Eligibility Criteria:

Eligible members are identified for enrollment in a variety of ways including the DMPR (Disease Management Prioritization Report), health appraisal results, referrals from the health plan (i.e., Case/Care Management), physician referral or a current or previous program participant.

How Members receive Health Coaching:

Member receive health coaching via telephonic outreach, education, and support services to assist them in addressing their health care needs as outlined in program goals. During the initial coaching session members are also screened for depression and referred to case management if applicable.

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. Several attempts are made to contact candidates by telephone at varying times of the day. Once contact is made, the program is explained to members, eligibility is confirmed, and an enrollment assessment is initiated to collect information and establish a communication preference. A health coaching call is then scheduled (or can be completed at that time) with a health coach specializing in the applicable focus area(s).

Disenrollment

Members may be disenrolled or excluded from the program under the following circumstances:

• Member dies.
• Members with serious or life-threatening medical conditions including mental health will be referred to case management.
• Member’s health care coverage with the health plan terminates or the health plan no longer provides the member’s primary coverage.
• Member is no longer capable of participation in the program in the reasonable determination of the health coach or the provider.

Exclusions

Services are excluded for members with certain conditions and diagnosis and conditions such as:

• Gestational Diabetes
• High Risk Pregnancy
• Hospice and/or no longer receiving curative care

Identification and Stratification

Data from multiple sources is integrated to identify members who may benefit from disease management. The report used to identify members for disease management includes, but is not limited to:

• Member prioritization report -- member screening information and other existing data is included in the Disease Management Prioritization Report, which leverages seven core Disease Management Conditions in combination with the CM implacability model.
• These seven conditions include diabetes, asthma, COPD, heart failure, coronary artery disease (including hypertension and ischemic heart disease), lifestyle (obesity and tobacco use).
• Screening for depression is part of the Disease Management/Health Coaching initial screening assessment, and the member is referred to a specialist if an intervention is indicated.

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.

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

For Medi-Cal members under age 21 with diabetes, 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.

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.