Provider Manual

Activities and Goals

EmblemHealth has a Population Health Management model that identifies prospective high-risk members who require help to meet their care needs. EmblemHealth's care management goal is to address our members’ needs in the following focus areas:

• Keeping members healthy.
• Managing members with emerging risk.
• Patient safety or outcomes across settings.
• Managing multiple chronic illnesses.

Using sophisticated predictive modeling tools, we can identify members with evolving risks and provide them with care as early as possible. We can also identify members who would most benefit from field-based care management. Our programs and initiatives are designed to complement the traditional medical care our members receive.

Activities include, but are not limited to:

• Providing care management services that include:
  • disease assessments
  • health education
  • depression screening
  • case management
• Screening for social determinants of health (SDOH) that can act as barriers to receiving care, such as access to suitable food, financial, or transportation issues. Directing members to appropriate resources.
• Collaborating with community-based organizations and hospitals to improve transitions of care from one setting to another and between different levels of care.
• Coordinating care between primary care practitioners and specialists, as well as behavioral health and medical practitioners.
• Supplying treating practitioners with member information regarding progress, educational materials, and other services.
• Scheduling outbound calls.
• Virtual/Face-to-face interactions with care management staff.
• Ongoing education, as appropriate to each program.

Program goals include:

• Improved adherence with physician instructions.
• Appreciable member continuum of care coordinated across potential settings, providers, and levels of care.
• Increased patient knowledge of their condition.
• Symptom improvement and/or stabilization.
• Reduction in inappropriate utilization.
• Positive behavioral health changes.

Members are identified for these programs through our analysis of:

• Health risk surveys.
• Claims data.
• Self-referrals.
• Caregivers.
• Discharge planners.
• Referrals from practitioners.

Practitioners may refer members to our care management programs, or the member may contact us directly at 800-447-0768 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday to Friday. 

Enrollment is voluntary and, if applicable, allows members to receive:

• Educational tools to assist with:
  • understanding their diseases
  • symptom management
  • diet and nutrition needs
  • treatment options
  • preparing for doctor visits
• An opportunity to work one on one with a nurse, social worker, or behavioral health care manager by telephone or face-to-face interaction.
• Access to community-based support services.
• Access to additional care through our other care management programs.

Program Components

The care management programs support practitioner care plans by using evidence-based clinical practice guidelines (CPGs) to highlight ways to prevent complications and flare-ups of chronic conditions. Clinical practice guidelines are updated regularly in Clinical Corner on emblemhealth.com. Check monthly for updates.

Key components include:

• Matching members with disease-specific programs that meet their individual needs.
• Prompting practitioners and members to follow evidence-based clinical practice guidelines in treating chronic illness.
• Coordinating care among:
  • medical and behavioral health practitioners
  • support services providers
  • the health plan
  • the member
  • caregivers
• Educating and empowering members to make lifestyle choices that may prevent or control their conditions (including behavioral modification and compliance/surveillance).
• Providing health coaching and monitoring centered around a care plan created by a registered nurse and/or other clinically trained or licensed health professional.
• Appropriate use of information technology including:
  • specialized software
  • data registries
  • automated decision support tools
  • tickler systems for materials and/or calls
• · Measuring progress and outcomes of care for quality improvement, reporting, and performance-based payment.

Note: For members with multiple chronic illnesses, or with severe or end-stage illness, patient preferences and needs should take precedence over guidelines-based care. Such members require highly individualized care plans and may not be suited for participation in some care management programs.