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Wellness
The goal is to
"Be Well."
It's like preventive maintenance.
Know what's going on with your
body, know the risk factors for future disease and how you
"measure up," then reduce your risk factors through nutrition,
fitness/activity, and smoking cessation, and medical treatment
if necessary.
What we do: Through a
Health Needs Assessment completed by all new members, optional
preventive blood screenings, patient education, web-based
information and tools, and personal assistance from the Care
Coordinators, we help employees and dependents:
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establish a regular
relationship with a family doctor
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have regular
preventive screenings to ensure earliest possible detection
of health problems
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understand risk
factors for future disease
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"know their own risk
numbers"
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reduce their risk
factors through nutrition, fitness/activity, and smoking
cessation
Disease Management
If you have a chronic
disease, our job is to help you
"Stay Well."
Some 60% of adult Americans have
one or more chronic diseases, which left unmanaged will progress
to an acute, costly, life-threatening stage. Many are highly
responsive to chronic management. Your health plan should ensure
that all family members are regularly screened, and once a
chronic condition is identified, educate you on self-management
and help you keep your disease from progressing.
What we do: Through
wellness screening, regular monitoring of claims data, patient
calls, referral/pre-cert notifications from physicians, and
post-discharge followup calls, we:
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Identify
patients with 86 "trigger" diagnoses and classify them as
Level I, II, or III based on acuity
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Aggressively case manage all Level III's
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Assist all patients with asthma, diabetes, heart/vascular
disease, back pain, and depression with a systematic disease
management process
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For Level II and III patients, obtain a Plan of Care from
physicians and work with patients to ensure they are
complying with physician direction and following
disase-appropriate "care pathways"
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Help patients detect early signs of degeneration and get
them to medical care before their condition worsens
Acute
Care Coordination
When acute illness or
injury strike, the Care Coordinators are there to help you
"Get Well." We work
directly with you, your family, your physicians, and their
office staff to help guide you through the confusing and often
frustrating "maze of healthcare."
What we do: The Care
Coordinators "advocate" for patients and families by providing
information and guidance. Through patient calls, utilization
management, concurrent review, case management, and
post-discharge followup, we:
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provide information and guidance to patients and their
families,
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explain your benefit plan, direct you to in-network
providers, and help maximize your benefits
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obtain and transfer information, records, help schedule
appointments, and expedite care
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directly coordinate with physician offices
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help resolve problems with claims payment
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