Disease Management Coaching

This is an excellent program to offer Members that do not meet specific care plan criteria but have one or more chronic conditions or diseases, and thus could benefit from the clinical management of these condition(s).

This program provides continuous support for Members who recently graduated from a care plan by mitigating the risk for members with challenging chronic condition(s), offering continued education and support for chronic condition management, and connecting Members to trained coaches and clinicians for support.

A Member may be identified for disease management coaching upon care plan graduation from the Care Coordination Program. This program is ideal for Members not in a care plan or Members who recently graduated the care plan but continue to manage their chronic condition(s).

To participate, a Member must have one or more of the following 10 chronic conditions below:

• Asthma
• Diabetes
• Coronary Artery Disease (CAD)
• Chronic Obstructive Pulmonary Disease (COPD)
• Heart Failure (HF)
• Chronic Low Back Pain
• Osteoarthritis
• Atrial Fibrillation
• Irritable Bowel Syndrome (IBS)
• Fibromyalgia

FEP PPO Members are only eligible for Disease Management Coaching if they have one or more of the following chronic conditions: diabetes, CAD, asthma, COPD, and/or HF. FEP PPO Members do not have access to lifestyle coaching, tobacco cessation or the Innergy® Healthier Weight program, however comparable WDM programs are available to FEP PPO Members through fepblue.org.

Members must be 18 years or older to participate in the program. However, children (17 years and younger) are eligible for the program only if they have asthma and/or diabetes. Parents will talk to the primary coach until the child turns 13. At that time, the parent can request the nurse to involve the child during calls.

In addition to identifying Members with the above conditions, the care coordinator can view a Member's health assessment in the Member portal to identify the appropriateness of wellness and disease management services.

The RealAge® health assessment offered to members includes:

• A Health Assessment Questionnaire that can identify the Member's health risk factors and suggest changes the Member can make to improve and maintain health. RealAge looks at eating, exercise and sleep habits, along with family dynamics, behaviors and existing conditions, to show the physical age of the body. These results arm Members with real-time information on how their lifestyle choices are helping them stay younger - or making them age faster - than their calendar age.
• A Biometric Screening of basic measurements including weight, height, BMI, cholesterol, blood pressure, nicotine and blood glucose levels.

After the service request is sent to Sharecare, Inc., the Member will be called telephonically by their personal Disease Management Coach. If a member is identified for both Lifestyle and Disease Management Coaching, due to the likelihood of the presence of multiple conditions, the Disease Management Coach will provide both services to eliminate confusion.

Once the Member is enrolled in the program, the coach then contacts the Member and provides the designated coaching services within the context of the Member's care plan (if applicable). The Member should be contacted within three business days following the service request submission, with a minimum of three attempts at contact over 10 business days (unless documented refusal is in the system).

The initial phone interaction will consist of:

• Obtaining participation consent
• Establishing defined goals
• Discussing call frequency
• Reviewing duration of future coaching session

The Member will be called every 4-6 weeks  thereafter, depending on Member need, preference and availability. On every call, Members will be asked to: 

• Verify first name, last name, full mailing address, and date of birth
• Answer priority risk questions which are assessed during each call to ensure there are no urgent issues/safety concerns that should be addressed

• Regularly scheduled coaching sessions
• Calls every 4-6 weeks depending on member need, preference and availability
• For missed appointments, coaches will call members at least once per week for up to 6 weeks to attempt to re-engage
• Regular visits to the well-being plan to update action steps and access resources
• Mailed educational materials in support of coaching call topics
• Mailed introductory letter for targeted members sent within one week
• Coaching sessions which are individually tailored to meet the members needs and goals
• Proposed action steps which are member-centric and appropriate for their stage of readiness
• Coaches tailor their approach to member need and expectation, accommodating a variety of learning styles and personality types
• All coaching is offered Monday through Friday 8:30 a.m. to 8:30 p.m. Eastern time and Saturday 8:30 a.m. to 5:30 p.m. Eastern time

The Member has completed Disease Management Coaching when:

• The Member graduates from their Program,
• The Member has a confirmed referral into the Care Coordination Program,
• The Member voluntarily or involuntarily terminates from the Program, or
• The Member is no longer covered by CareFirst.