Population Health Management Programs

Anthem is committed to maintaining or improving the physical and psychosocial well-being of our members by delivering the highest quality care and providing tailored health solutions while lowering the total cost of care.

The focus includes PHM programs that target Keeping Members Healthy, Managing Members with Emerging Risk, Patient Safety or Outcomes Across Settings, and Managing Multiple Chronic Illnesses. The programs include:

 

Keeping Members Healthy

 

Future Moms:

This program offers care and treatment leading to overall healthier outcomes for mothers and newborns. The program helps expectant mothers to focus on early prenatal interventions, risk assessments and education. Future Moms primarily delivers support through telephonic education from our nurses. All members have toll-free telephonic access to the nurses, who identify the needs of members, reinforce the provider’s treatment plan and help coordinate care to achieve optimal outcomes. The program also includes valuable educational tools and post-delivery follow-up. The Future Moms program for maternity uses a voluntary opt-in model.

Enhanced Personal Health Care (EPHC):

Anthem developed a patient-centered, value based program, known as Enhanced Personal Health Care (EPHC). Our patient-centered model redesigns primary care reimbursements to reward physicians for aspects of care that are most important to good patient outcomes. For instance, additional payments are given to physicians to support care coordination and preventive activities that improve the health of our members without requiring an office visit to perform the care. The EPHC program helps to close communication gaps between Primary Care Physicians and specialists and strongly promotes the support of care coordination by clinical staff within physicians’ practices.

 

Health and Wellness Programs

 

General Health and Wellness

On a bi-annual basis, Health Plan Presidents and Medical Directors review local quality performance and discuss improvement goals. All business areas identify priority measures and tailor plans and offerings to be implemented for the members. Below are the current interventions offered to all members.

Maternity Checklist:

This intervention is targeted to all Commercial, Marketplace and FEP PPO members who are identified as pregnant via claims data. The mailer includes a checklist of key items to keep in mind, such as getting a car seat, enrolling baby into the health plan, returning to work and getting the postpartum check-up within 4-6 weeks after delivery. The list also includes the recommended schedule for prenatal, postpartum and well infant checkups. This checklist is sent on a monthly basis to newly identified pregnant members. The use of these checklists are to promote health and wellness in our populations which can impact improvement with the HEDIS® rates.

Personal Health Checklist:

This checklist provides Commercial and Marketplace adult members with a personalized list of preventive and chronic care screenings that the member needs to complete during the year, as well as medication management tips when appropriate. Members will be encouraged to see a doctor for a yearly check-up, in addition to being provided general preventive care and vaccine reminders. Members may receive the email communication once a quarter if the identified services have not been completed. The use of these checklists are to promote health and wellness in our populations which can impact improvement with the HEDIS® rates.

 

Managing Members with Emerging Risk

 

Pharmacy Home/MQA Program :

Anthem’s Pharmacy Home program for Commercial and Marketplace members enhances patient safety by assigning individuals to one pharmacy when a review of pharmacy claims demonstrates behavior that can put individual at risk for controlled substance addiction and abuse. Emergency prescriptions are excluded from this program as well as members with cancer, HIV, multiple sclerosis or sickle cell anemia, where high use of controlled substances are anticipated. In the first year of implementation this program has shown a reduction in the use of controlled substances, an increase in the number of members using Medication-Assisted Treatment (MAT), and a decrease in emergency room and urgent care visits.

Complex Case Management:

Complex Case Management program focuses on the timely, proactive, collaborative, and member-centric coordination of benefits and community services for individuals identified with complex medical conditions. Care Managers identify members with potential Case Management needs by medical diagnosis or condition, and evaluate each member’s needs to develop an individualized plan and adjust interventions to facilitate linking members with complex Case Management services that meet their needs and goals. Members, caregivers or practitioners can refer into the program.

 

Patient Safety / Outcomes Across Settings

 

Cancer Care Quality Program:

This program is a provider-focused initiative, with the goal of helping to provide access to quality and affordable cancer care for members by collaborating with providers to create the framework to begin to transform cancer care – achieving higher quality and patient-centered care.

Behavioral Health Follow-Up After Discharge:

It is critical to follow-up with an outpatient provider shortly after discharge from inpatient care in order to maintain and continue the improvement that began during the hospitalization. Individuals that see an outpatient BH provider promptly after discharge have better continuity of care, fewer readmissions, and better treatment compliance. The goal of this program is to improve the percent of members that have a follow up visit within 7 days of discharge from an inpatient psychiatric setting. Follow up visits can be in traditional behavioral health outpatient provider offices, Intensive Outpatient Program settings, Partial Hospital or Residential Treatment Center (RTC) Programs.

Preventing Hospital Readmissions with the Post Discharge Call Program (PDCP):

The most common cause of readmissions is insufficient member preparation for hospital discharge and lack of post-discharge monitoring. Literature demonstrates many readmissions can be prevented with adequate communication of discharge instructions and post discharge monitoring to identify gaps in care and transition in care issues. The Post Discharge Call Program (PDCP) was developed to help reduce emergent readmissions within 30 days of discharge. Nurses utilize a care management assessment tool.

 

Managing Multiple Chronic Illnesses

 

Disease Management

The Disease Management (aka ConditionCare) Program is designed to help maximize health status, improve health outcomes, and reduce health care costs for members diagnosed with Asthma (Pediatric and Adult), Diabetes (Type 1 and Type 2, Pediatric and Adult), Coronary Artery Disease (CAD), Heart Failure (HF), and Chronic Obstructive Pulmonary Disease (COPD). This DM program was created and developed based on recent versions of nationally accepted evidence-based Clinical Practice Guidelines.

COMB

The primary goal of the Comorbid Medical/Behavioral Program (COMB) for Commercial/Marketplace members is to provide members who have chronic medical conditions with a comprehensive behavioral health case management program to address overall needs, support members into appropriate levels of care, and enhance treatment compliances. The purpose of the program is to manage members who have both a medical and behavioral health issue.

Informing Members

Members receive information regarding the PHM programs offered by the Plan through a variety of methods. These include health plan website, phone calls, and mailings. General information regarding programs is available for our Commercial and FEP members through member newsletters which are distributed annually. Further descriptions of care management programs are also available on the Anthem and FEP Blue websites. The toll free customer services number on the back of member ID card may be contacted to enroll in these programs

Supporting Providers through Tools and Education

Anthem is addressing health disparities through evidence-based research, robust analytics and program design, innovative strategies and caring solutions. We have also created programs that help medical practices address the special needs of diverse audiences.