“Whole person” care management

CareOregon, Health Integrated join to enhance services for members with chronic illness

CareOregon has joined with Health Integrated, a leading provider of integrated care management services, to expand these services to a larger portion of CareOregon’s member population.

CareOregon will use Health Integrated’s Synergy Targeted Population Management™ program to provide coaching, education and support to enhance management of diabetes and depression while reducing avoidable health care utilization and costs.

The Synergy program was launched the third week of March.

“We’re dedicated to providing health care access for Oregonians who are most at risk,” says David Ford, chief executive officer of CareOregon. “We have an extensive CareSupport effort that uses a team approach to support members’ behavioral and psychological health along with their physical conditions as part of a whole-patient approach. By partnering with Health Integrated, we can expand our work in a couple of key health areas. We believe the Synergy program will help us to further empower members to take charge of their own health.”

CareSupport Behavioral Health Specialist Buck Clarke provides motivational coaching to a CareOregon member. Photos by Eleanor Gorman

And that advances CareOregon’s mission to support Oregonians in achieving their health goals regardless of income or social circumstances, he says.

Chronic illness affects 140 million Americans and accounts for a disproportionate percentage of health care costs. Chronically ill patients with depression or diabetes are clinically complex and often struggle with social, psychological or behavioral factors that make their medical conditions worse and increase care costs through avoidable and inappropriate health care utilization. A high percentage of Medicaid patients suffer from these conditions.

Both Health Integrated and CareOregon follow an integrated approach to care management for people with chronic illness. Medical and psychosocial issues that have an impact on a person’s wellbeing are considered.

Rebecca Ramsay, manager of CareOregon’s CareSupport Unit, says CareSupport teams composed of nurse case managers, behavioral health case managers, health care guides and clinical pharmacists help patients find critical resources, resolve difficult behavioral and self-management issues and improve their ability to follow treatment plans. CareSupport targets members who have multiple conditions that make it more likely they’ll have difficulty following a treatment program without the additional help.

The alliance with Health Integrated will allow CareOregon to expand that approach to a larger number of members with diabetes or depression. An estimated 7,000 CareOregon members have one or both of the diagnoses.

Unlike care management programs that focus on a single condition, CareOregon’s CareSupport and Health Integrated consider all conditions a patient may have.

“We work in ‘non-silo’ disease management,” says Amber Steffenson, Health Integrated senior director of client services. “We work with the member as a whole. We make sure what’s best for the member is what is being done.”

For example, if a Synergy care coach is working with a CareOregon member who has congestive heart failure, obesity or depression in addition to diabetes, then the coach will work with them on those conditions as well, Amber says. If there are issues of poverty, then the Synergy care coaches will help address them, just as CareOregon’s CareSupport team does.

Health Integrated recently received accreditation for exceeding the nation’s highest performance standards in seven disease areas, including diabetes and depression.

While the Synergy program’s care coaches communicate with patients and providers by phone, there will be an outreach coordinator based at CareOregon who will work with providers at their locations.

All Synergy care coaches are certified in motivational interviewing, which is also a key component of CareOregon’s CareSupport program.

The Synergy program is available to all CareOregon members who fit the population criteria, except for those members whose primary care is provided by one of the Primary Care Renewal clinics. These clinics already provide integrated care management to their patient populations.

“CareOregon is an innovative plan and a leader nationally in advancing the patient-centered medical home through its primary care renewal initiative,” says Sam Toney, MD, vice chairman and chief medical officer at Health Integrated. “We are thrilled to work with a group that understands how to integrate treatment approaches that address the whole patient, including a member’s physical, behavioral and psychosocial issues.”