Provider Manual

Chapter 9: Health Promotion and Care Management

 

 

In this chapter you will find quality improvement programs available to help members with identified conditions and diseases.

 

EmblemHealth has health and wellness programs, tools and resources to help members stay fit and enhance their quality of life. EmblemHealth members have access to Healthy Discounts programs at no additional cost. Participating vendors offer discounts off their usual and customary fees for health club memberships, acupuncture, massage therapy and nutrition counseling, weight loss services, hearing and vision care, vitamins and supplements, and other comprehensive health care services and products.  

Some member benefit plans include the ExerciseRewardsTM Program, a gym membership reimbursement program where members can get back up to $200 of their membership dues.

EmblemHealth promotes the following quality improvement initiatives for EmblemHealth, GHI and HIP plan members through member and provider newsletters, and other educational materials:

Women's Wellness

  • Breast health and mammography
  • Cervical cancer screening
  • Chlamydia screening
  • Osteoporosis and musculoskeletal health
  • Timely prenatal and postpartum care

Adult Health

  • Cardiac care
  • Cholesterol management
  • Colorectal cancer screening
  • Depression screening
  • High blood pressure management
  • Influenza and pneumonia vaccinations
  • Stress management
  • Weight management
  • Appropriate use of antibiotics
  • Respiratory management (COPD and asthma)
  • Medication management and safety

Childhood and Adolescent Care

  • Well-care visits
  • Vaccinations
  • Lead screening
  • Dental screening
  • Depression screening
  • Adolescent immunizations
  • Adolescent screening and counseling for:
    • Exercise
    • Nutrition
    • BMI and weight management
    • Sexual activity
    • Tobacco and substance abuse
    • Appropriate use of antibiotics

Counseling

  • Smoking
  • Alcohol
  • Substance abuse

Clinical practice guidelines are updated regularly on emblemhealth.com. Please check updates on a monthly basis.

Overview

EmblemHealth has set up a Population Health Management model. It identifies members who require help to meet their care needs. 

 

EmblemHealth’s strategy is focused on keeping members healthy, managing those members with emerging risk, assessing social determinants of health, patient safety, and supporting members who have multiple complex health conditions.

 

Using sophisticated predictive modeling tools, we can identify members with developing risk to engage them earlier, as well as identify members who would most benefit from field-based care management. 

 

Members’ needs are addressed through various initiatives. In the past, members with chronic conditions would have been managed through a standalone disease management program. Now, they are identified through our predictive modeling data, so we can provide them with the appropriate care.

 

Focus on care management programs assists with the overall care management of members. Our programs are designed to complement the care our members receive.

 

Activities include, but are not limited to:

  • Collaborating with community-based organizations and hospitals to improve transitions of care from one setting to another and different levels of care.
  • Coordinating care between practitioners and specialists, and behavioral health and medical practitioners.
  • Providing information to you (the physician) regarding progress, member educational materials, member calls as appropriate, and other services as noted on the EmblemHealth website.
  • We offer:
    • Scheduled outbound calls.
    • Field-based care managers’ face-to-face interactions.
    • Ongoing education, as appropriate to each program.

 

Referrals for these programs are received through health risk surveys, claims data, self-referrals, caregiver referrals, discharge planner referrals, or directly from you, as the practitioner.

 

Program goals include:

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

 

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, and planning 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.

 

Care Management Program Components

The care management programs support practitioner care plans by using evidence-based clinical practice guidelines (CPGs) to emphasize ways to prevent complications and flare-ups of chronic conditions.

 

Key components include the following, as applicable:

  • 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 amongst practitioners, support services providers, the health plan, the member, and 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.
  • Making appropriate use of information technology. This may include specialized software, data registries, automated decision support tools, and tickler systems for materials and/or calls.
  • Measuring progress and outcomes of care for quality improvement, reporting, and performance-based payment purposes.

 

Healthy Beginnings Pregnancy Program

The Healthy Beginnings pregnancy program helps eligible members better understand and manage their pregnancies and gives them support and education throughout their pregnancy. Program services include:

  • A series of health-risk surveys that identify potential high-risk factors.
  • Specialized care management services for members identified with risk factors.
  • Comprehensive educational materials.
  • Access to a 24-hour toll-free Nurse Line staffed by experienced nurses able to answer questions on pregnancy-related topics (note, no medical advice is given).
  • Depression screening.
  • Reminder mailings encouraging postpartum visits.

 

EmblemHealth follows New York State Prenatal Care Assistance Program (PCAP) guidelines to provide comprehensive care and information to women during and after pregnancy.

 

Healthy Beginnings pregnancy program provides screenings for high-risk behaviors, depression, tobacco, and drug and alcohol use, as well as education to expectant mothers about community services available in their area. Medicaid members also receive child birth/parenting education and receive WomenInfants and Children (WIC) Food Nutrition Service Program referrals free of charge.

 

More information, clinical guidelines, and resources can be found online at the PCAP website at health.state.ny.us/nysdoh/perinatal/en/pcap.htm.

 

For more information about the Healthy Beginnings pregnancy program, or to refer a member, please call 888-447-0337 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday through Friday.

 

Tobacco-Free Quit-Smoking Program

EmblemHealth has partnered with the New York State Smokers Quitline to provide comprehensive smoking cessation services. New York State Smokers Quitline is a state program based at the Roswell Park Cancer Institute in Buffalo, NY. The program is available at no cost to all individuals residing in New York State.

 

Services available through the New York State Smokers Quitline include:

  • Help developing a quit plan by phone from trained quit-smoking experts.
  • Recorded phone messages and tips available 24 hours a day, seven days a week.
  • Receipt of educational guides and materials by mail.
  • A two-week supply of nicotine replacement therapy (nicotine patch or gum) for those who qualify.
  • Access to information and services through the New York State Quitline website.
  • Full coverage for smoking cessation medication (nicotine patch, gum, lozenge, bupropion [generic Zyban®], and Chantix®) for members with EmblemHealth pharmacy benefit coverage enrolled in the Tobacco-Free quit-smoking program. Medicare members will be responsible for a copay for the smoking-cessation prescription products.

 

Practitioners are encouraged to refer members directly to the New York State Smokers Quitline at 866-NY-QUITS (866-697-8487), or 311 in New York City. Referral forms can be found online at nysmokefree.com. For out-of-state members, referrals can be made directly to the program by calling 877-500-2393.

 

Studies show that a follow-up visit or phone call within one week of the patient's quit date can double the effectiveness of any intervention. EmblemHealth provides reimbursement for smoking-cessation counseling based on current Centers for Medicare & Medicaid Services guidelines. We will reimburse for CPT codes 99406 and 99407.

 

We also offer a Tobacco-Free quit-smoking program.

For clinical practice guidelines, go to the Clinical Corner on our website.

 

Healthy Living Program

EmblemHealth provides many tools to help members manage their weight.

 

For more information about body mass index (BMI), clinical practice guidelines, recommendations, coding and tools, and the Childhood Obesity Action Network's implementation guide to prevention and treatment of childhood obesity, visit the Provider Weight Management Resources section of our website.

 

Serious and Persistent Mental Illness Disease Management Services

Our Serious and Persistent Mental Illness Disease Management Services is designed to help members with serious mental illness and high risk of hospitalization remain engaged in treatment in the most appropriate and least restrictive settings possible.

 

This program, delivered by master's-level clinicians, emphasizes communication with practitioners and family members, proper medication and treatment adherence, education for members and their families, access to community resources, and coordination of care.

 

HIP members may be enrolled by calling 888-447-2526 (TTY: 711)/GHI members 800-692-2489 (TTY: 711). If your patient’s ID card has a Montefiore logo in the lower left corner, please call 800-401-4822 (TTY: 711) for help finding a mental health or substance abuse practitioner.

 

Contract Management Organization Programs

The Contract Management Organization (CMO) programs are delegated for EmblemHealth plan members who receive treatment under the care of a CMO (i.e., Montefiore Medical Center) provider. They offer care management programs for members with chronic medical and behavioral health conditions.

 

For questions or more information about CMO Programs, please call 844-209-4932 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday to Friday.

 

Note: For members with multiple chronic illnesses, or with severe or end-stage illness, this guidelines-based care should not take precedence over the provision of care that corresponds to patient preferences and needs. Such members require highly individualized care plans and are therefore typically not suited for participation in some of the care management programs.

EmblemHealth serves our members across all health plans, as well as the communities where our members live, with innovative, evidence-based programs that promote healthy living and advance better health outcomes.

 

Care for the Family Caregiver provides informationresources and support to promote awareness and understanding of the key role of the family caregiver within the health care system. Through its programs for members and employees, community outreach and partnerships, Care for the Family Caregiver provides support and encouragement to family caregivers to keep them from becoming care recipients. Programs such as Seniorlink are of particular interest to family caregivers with long distance caregiving needs. Seniorlink's national network provides expert assistance in developing senior care planning, regardless of where the care recipient lives, and helps reduce the stress of navigating a complex eldercare system. EmblemHealth continues to host and sponsor the NYC Family Caregiver Coalition. More  informationresources and support may be found in the Care for the Family Caregiver webpage.

 

CME Events and Other Educational Opportunities

 

Educational opportunities in the arenas of mind and body medicine, self-care and spirituality and belief are available to the EmblemHealth provider community.

 

Currently, we support this commitment with our continuing medical education (CME) event: the Carl E. Flemister Symposium on Mind/Body Medicine, Spirituality and Health. This symposium makes available to our practitioners the most recent scientific research on the biology and physiology of belief and helps them to consider ways to make this research relevant in their practices. Leading experts on spirituality and health are invited to speak at the symposium.

 

We have also published a first-of-its-kind training and resource manual called The Medical Manual for Religio-Cultural Competency: A Comprehensive Resource for Providing Quality Care in a Diverse Health Care Setting, written by the Tanenbaum Center for Interreligious Understanding. Practitioners can now look to one resource to provide practical information on how the beliefs and practices of 10 of the world's major religious traditions intersect with medical science. This manual is packed with readily-accessible information for the busy health care practitioner who wants to be religio-culturally competent. Its wide-ranging chapters include practical information on different religions, spiritual assessment forms and tools, and tips for working effectively with people of diverse religious backgrounds and points of view. You may access The Medical Manual in its entirety by signing in to emblemhealth.com.