In support of the Centers for Medicare and Medicaid (CMS) Chronic Care Improvement Plan (CCIP) —a five-year project aimed at reducing cardiovascular (CV) risk— Harvard Pilgrim conducts outreach to Medicare Advantage Stride HMO members with diabetes in an effort to improve blood pressure control.
This work complements the Million Hearts campaign’s efforts to prevent one million heart attacks and strokes by 2017 by emphasizing a variety of heart healthy behaviors, including blood pressure control, cholesterol management, smoking cessation, and aspirin therapy when appropriate.
The primary components of Harvard Pilgrim’s CCIP program are telephone outreach to all Medicare Advantage members with diabetes and the development of a coordinated care plan.
Telephone outreach program
During member calls, our disease case managers complete patient assessments based on recommendations of the American Diabetes Association. Our disease case managers:
- Assist the member in identifying lifestyle changes (such as weight management, blood pressure control, improved nutrition, exercise, and smoking cessation) that may prevent chronic symptoms, disease progression, and serious complications
- Discuss medication safety and the importance of continuing to take medications as directed
- Address functional and behavioral health issues to prevent health problems from developing
- Assess the patient’s knowledge of diabetes, including his or her understanding of hemoglobin A1c, lipid panel results, blood pressure, and the benefits of regular visits with providers
Helping members manage their disease
The CCIP program is designed to reinforce the clinician’s treatment plan, and our disease case managers collaborate with the member and the primary care physician (PCP). After conducting an assessment, the disease case manager works with the patient to develop a care plan that outlines problems, interventions, and goals, and shares the plan with the PCP.
If one of your Harvard Pilgrim Medicare Advantage patients has diabetes, our disease management department may contact your office to obtain the patient’s most recent lab results for this outreach program. If you have any questions on our CCIP program, please contact 888-211-9913.