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Provider Manual

Chronic Care Management

Last Updated on May 22, 2021

Security Health Plan offers a Chronic Care program to select members who have a diagnosis of asthma, diabetes, heart failure, chronic lung disease and/or coronary artery disease. The program focuses on promoting member self-management of their condition and coordinating needed health care services. Members over the age of 18 with one or more of these chronic conditions receive targeted educational mailings and/or interactive voice recognition calls that address potential care needs and/or pertinent gaps in care. High-risk members are identified through a variety of data sources as well as through referrals from providers, family, and other concerned individuals. These members receive telephonic outreach by a care manager who conducts clinical assessments of health status and current health needs and reconciles medications on admission and at care transitions. Members who elect to enroll in ongoing care are contacted regularly. Their providers’ plan of care is supported, and members are encouraged to keep their providers updated on relevant health issues. Appropriate referrals to social workers, health coaches, community and other support resources are made independently, and providers are contacted for suggested referrals that require a provider order. Care managers focus on member education to optimize their self-care ability and promote their active participation in health management.

Security Health Plan’s Chronic Care program is for members over the age of 18 who have asthma, diabetes, CAD, CHF, COPD, hypertension, and/or hyperlipidemia to improve the coordination of care and self-management  with these conditions.  Members who have one or more of the chronic conditions listed above will receive targeted educational mailings  that address any pertinent gaps in care.  High risk members will also receive telephonic outreach and/or in-person visits from an RN care manager. RN care managers conduct clinical assessments of health status and comorbidities, support a provider’s care plan, communicate regularly with the provider, make referrals to social workers, health coaches and community resources, perform medication reconciliation and educate the member in order to optimize the member’s self-management skills. 

For more information about clinical practice guidelines, click here.