We implement this strategy using an integrated approach among health care professionals. Care coordinators serve as the liaison between members and health care providers, coordinating care and services while also performing educational and patient advocacy roles. Home health care is also an important component of many disease management programs. Patients with moderate to severe Congestive Heart Failure have been documented to improve their functional status through a CHF disease management program. All of these programs require an investment in staff, materials and information systems to be successful.
Nurses regularly call members to assess their progress.
Patients who appear not to be improving are referred to their primary care physicians or specialists for assessment and modification of their treatment. With care management, medical problems are identified and addressed earlier, avoiding potential risk to the patients, hospitalizations and medical costs. AvMed and others are looking at new technology that will allow us to more efficiently monitor larger numbers of patients, with lower administrative costs. Today we have a pilot program in which each morning our members step on an electronic scale, which weighs the member, asks several key clinical questions and then electronically transfers this information to AvMed. Those members reporting worsening symptoms or weight gain above limits set by their physicians are contacted by one of our nurses.