HNE wants to help our members with chronic health conditions live healthy lives. As part of our commitment to these members, we offer Disease Management (DM) programs for members with diabetes, asthma, and dyslipidemia.  Through our DM programs, HNE works with physicians in support of the plan of care. The overall goal of this collaborative effort is to help members achieve and maintain control of their condition by improving self-management skills. Self-management skills affect clinical outcomes, and are important in delaying and preventing exacerbations and complications of chronic disease. HNE DM programs provide members with education and support to help improve their ability to manage their health condition on a day-to-day basis.   

What is Disease Management?
The Disease Management Association of America (DMAA) defines Disease Management as a system of coordinated healthcare intervention and communication for populations with conditions in which patient self-care efforts are significant .[1]

Disease Management:

• supports the physician (practitioner)/patient relationship and plan of care;
• emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and
• evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health.

Clinical Practice Guidelines
Evidence-based Clinical Practice Guidelines are the basis for each DM program. You can view the following guidelines from our Web site or by clicking on the links below: 

Asthma
Practical Guide for the Diagnosis and Management of Asthma (NIH Publication No. 97-4053 October 1997) (available for you to view at http://www.hne.com/HNE_members/preventive/medguides/04HMPCGuide11-15.pdf)

Diabetes
Massachusetts Guidelines for Adult Diabetes Care (Diabetes Prevention and Control Program, Massachusetts Department of Public Health) (available for you to view at http://www.hne.com/HNE_members/preventive/medguides/04HMPCGuide35-63.pdf)

Dyslipidemia
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) (NIH Publication No. 02-5215 September 2002) (available for you to view at http://www.hne.com/HNE_members/preventive/atpIII.pdf)

How We Identify and Stratify Members

On a quarterly basis, HNE identifies the following member populations based on review of HNE claims/encounter and pharmacy data:

• Members aged 18 or older with diabetes;
• Members with asthma - all ages; and
• Members aged 18 or older with high blood cholesteroland/or secondary risk factor.

HNE uses the most recent HEDIS® specifications to identify these members. In addition, providers may refer members to DM programs, or members may self-referral. Upon identification, members are stratified into a risk category based on certain parameters. The following charts show HNE's stratification criteria for asthma and diabetes:

Asthma
Inpatient and emergency utilization are used to determine stratification. Utilization data is obtained by review of claims/encounter data containing a primary diagnosis of asthma (ICD-9 code 493). Members are stratified upon enrollment into the program and quarterly thereafter. 

Stratification	Inpatient Admit / ER Criteria
Low-Risk	No inpatient admits or  ER visits in 12 months
Medium-Risk	1 to 2 ER visits in 12 months –or– 0 inpatient admit in 12 months
High-Risk	3 or more ER visits in 12 months   –or– 1 or more inpatient admit in 12 months

Diabetes
The A1C level is used as the marker for stratification.  A1C data is obtained electronically from in plan laboratories, medical record review, and practitioners.  Members are stratified according to their A1C level upon enrollment into the program and quarterly thereafter. 

Interventions Based on Stratification
HNE provides different levels of intervention based on a member's identified risk level. HNE mails members in the lowest risk category educational materials and conducts workshops for members at this level. Members in the highest level of risk, in addition to the aforementioned educational components, are contacted by a Nurse Case Manager who conducts an assessment and provides education and support telephonically.

HNE DM Programs provide members with the following services:

• Educational materials
  Examples of educational materials produced by HNE include the Living Well with Diabetes workbook.  This resource contains comprehensive information about managing medication, physical activity and meal planning, and preventing short-term and long-term diabetes complications.  Another tool offered by HNE is the Asthma Action Plan, based on the NHLBI "red-yellow-green" peak flow level concept. Members are instructed to complete the Action Plan with their healthcare providers.
• Questionnaires
  HNE's Asthma Survey (adult and pediatric versions) collects self-reported information about asthma control and self-management; including use of medications, perception of asthma severity, use of a written asthma action plan, and peak flow monitoring practices. Responses are shared with the members' primary care physicians (PCP).
• Tracking tools
  The Health Record Calendar Checkbook is a log for recording and tracking blood glucose levels, A1C, blood pressure, and other test results.  Members are encouraged to share this information with their healthcare providers.
• Live education workshops
  HNE offers diabetes and asthma education classes several times throughout the year, facilitated by a certified diabetes educator and certified asthma educator.
• Virtual education classes
  For members unable to attend a live workshop, and as a refresher for those who do attend, HNE offers diabetes and asthma workshops on DVD, narrated by a certified diabetes educator and certified asthma educator.
• Smoking cessation
  HNE reimburses members up to $50 for participation in a stop-smoking program.
• Newsletter
  Several times a year, HNE publishes and distributes Living Well with Chronic Conditions, a newsletter that contains information and tips related to daily self-management of chronic disease.
• Nurse Telephonic Assessment
  For members with uncontrolled disease and who stratifiy into high-risk categories, an RN performs an assessment and determines individual needs and goals to improve self-management skills.

How to Refer a Member to HNE Disease Management
If you have a patient who may benefit from DM interventions, call HNE Health Services at 413-787-4000, ext. 3553.