Preventive Health, Disease and Case Management

• Disease Management Programs
  • MOM Matters^® Program
  • Asthma Program
  • Diabetes Program
  • Help Your Heart Cardiac Program
• Special Needs/Case Management
  • General Information
  • Criteria for Referrals to the Special Needs Case Management Unit
  • High-Risk Case Management Program-StatusOne

Gateway MOM Matters^® Perinatal Program is designed to help each woman have a healthy baby.  Specific goals of the program include:

• Reduce prematurity (less than 37 weeks gestation)
• Reduce low birth weight deliveries (less than 2500 grams)
• Reduce timeliness and frequency of prenatal care visits
• Reduce NICU average length of stay
• Increase rate of postpartum visits

All pregnant Gateway members can participate in the MOM Matters^® Program and have access to Maternity Case Managers Monday through Friday, 8:30 AM to 4:30 PM at 1-800-642-3550.   After hours and on holidays the Member Services Department is available at 1-800-392-1147.

Authorization for ante-partum visits is required.  The authorization requirement for up to two routine mom/baby home health visits following delivery has been eliminated.

Included below are important details related to this change in the authorization process:

• The elimination of the authorization is for two routine mom/baby visits. These visits would normally be billed under codes W1772 or W0533.
• In response to practitioner's comments, these two visits can occur on two separate dates of service, or can be combined to one longer mom/baby visit on one date of service.
• Authorization will continue to be required in the following circumstances:
  • if more than 2 mom/baby visits are necessary; or,
  • additional skilled visits are required for either mom or baby; or
  • any other circumstance that normally would have been billed under code W0529

If a visit is billed using code W0529, and no authorization is obtained, the claim will be denied.  Documentation of visits by home health providers is required. For explanation or copies of the documentation please call the Maternity Nurses at 1-800-642-3550, option #2.

Please note, any W codes referenced in this section are MA local codes; therefore, the codes will be obsolete sometime in 2005.

"AIR" Gateway^® (Asthma Intervention gets Results) is a comprehensive Program for asthma management that emphasizes patient education, self-management, and practitioner education.  The program is intended to help the entire population of members diagnosed with asthma to keep the condition under control.  Members with asthma are identified through the enrollment process and through pharmacy and medical claims.  All members, 2-56 years of age and diagnosed with asthma are eligible for the program and receive interventions based on level of utilization of healthcare services.  Members with Medicare and a diagnosis of COPD are excluded from the program.

Educational information received by the member includes personalized letters from the Medical Director stating that they can get a peak flow meter with a prescription from their primary care practitioner.  Member newsletters titled Gateway to Health are published several times a year with information and announcements about the "AIR" Gateway^® Program.  Educational messages are played annually in May (Asthma Awareness Month) regarding asthma management and annually during flu season, regarding the importance of influenza vaccines while members are on hold.  Asthma action plans are mailed out to identified asthma members.

In addition to this education, Asthma Nurse Care Managers telephonically work with members who are at higher risk of complications due to their asthma based on inpatient and emergency utilization date, as well as from member and/or practitioner referrals.  The Nurse Care Manager establishes goals for the individual member and coordinates care between the member and practitioner.  Home care referrals can be used as an adjunct therapy to enhance member education and home assessment.

A fax form is also available for referral into the program.  Practitioners and members can also call 1-800-642-3550, option 3, for referrals into the "AIR" Gateway^® Program.

Gateway's Healthy Returns Diabetes Disease Management Program provides education and support to improve the diabetic members' quality of care, quality of life, and to reduce resource utilization.  The program is provided at no cost to Gateway members by Health Management Corporation (HMC) of Richmond, Virginia, 24 hours a day, seven days a week. 

HMC interventions are provided telephonically, by nurses, and are based on the American Diabetes Association (ADA) Clinical Practice Recommendations (2000) and the American Association of Clinical Endocrinologists (AACE) Guidelines for the Management of Diabetes Mellitus (1995).  Members and practitioners also have access to pharmacists and dieticians through the program.

The primary approach provided by HMC entails education and support interventions driven by a disease-specific health appraisal and assessment.  In conjunction with the practitioner's plan of care, goals are set and progress monitored.  The primary care practitioner and specialist are kept informed of the member's progress in the program by regular written reports.

In addition to identification via claims data, members may self-refer, be referred by their practitioner, or are identified by Gateway case managers.  The Program is offered to non-Medicare member of all ages.  To initiate a referral to HMC, call 1-866-366-3415.

The Gateway Help Your Heart Cardiac Program is intended to help members with congestive heart failure (CHF), myocardial infarction (MI) and coronary artery disease (CAD) understand and control their disease.  The intent is to decrease the emergency room visits, decrease or eliminate the need for hospital admissions and support practitioners in managing this population.  Controlling these diseases will subsequently decrease associated co-morbidities.

Criteria for the Cardiac Program includes:

• Members age 21 and older with a primary diagnosis of CHF, MI, or CAD having one inpatient or two emergency room visits associated with their cardiac condition within 12 months;
• Medicare primary are excluded at this time.

Gateway identifies eligible members monthly with claims data and contacts members to educate them about the Cardiac Program.  The primary care practitioner is informed of their members who have agreed to participate.  Interventions are provided telephonically by Gateway nurses to educate the members in the importance of daily weights, limiting salt and fat intake, proper compliance with medications, LDL lab values, blood pressure control, and members are taught the medications they are ordered and the rationale for taking them.  They are offered guidelines in energy conservation and the nurses work with the practitioner to determine an action plan when the member develops weight fluctuation of 2 or more pounds in one day, or 5 pounds in one week.  Members are provided with an introductory packet of guidelines for the above topics.

ACE Inhibitors are of primary importance in the control of the disease; therefore, Gateway Nurse Care Managers will contact the practitioner office if a member is not on the medication.  The nurse will attempt also to verify the ejection fraction of the member to determine limitations in ADLs and will contact the primary care practitioner or Cardiologist for this information.

The treating practitioner will be updated bi-annually with members in their panel who are participating in the Cardiac Program.

Gateway has made provisions to provide scales for members up to 345 pounds if necessary.

Practitioners are encouraged to order a home care nurse assessment for their members when an inpatient admission occurs secondary to CHF or an MI.

A practitioner can initiate a referral into the Help Your Heart Cardiac Program by calling 1-800-642-3550, option 3.

The goal of the Special Needs Case Management Unit (SNCMU) is to intervene in medically or socially complex cases that may benefit from increased coordination of services to optimize health and prevent disease.  The SNCMU is staffed by individuals with medical or social service backgrounds in the following areas: oncology, medically complex children, HIV/AIDS, substance abuse, mental health, physical rehabilitation and mental retardation.

A Special Needs Case Manager is available at 1-800-642-3550, option 1, Monday through Friday from 8:30 AM to 4:30 PM to assist with coordination of the member's healthcare needs.  When calling after hours or on holidays, Member Services is available at 1-800-392-1147.

Case management is a creative and collaborative process involving skills such as assessment, planning, coordination and advocacy.  Case management facilitates optimal patient outcomes.  Early intervention is essential to maximize treatment options while minimizing potential complications associated with catastrophic illnesses or injury and exacerbation of chronic conditions.  The case management process includes:

1. Assessment
2. Planning
3. Intervention
4. Quality Monitoring
5. Evaluation/Reassessment

The responsibilities of the SNCMU include:

• Liaison with various healthcare practitioners, community social service agencies, advocacy groups and other agencies that the Medical Assistance population may interface with;
• Case management of members with medically complex special needs;
• Coordination of services between primary care, specialty, ancillary, and behavioral health practitioners within and outside the network;
• Facilitation of dispute resolution including informing members of the complaint, grievance and appeal mechanism that is available to the member.  Facilitation of members' access to city, county and Commonwealth social agencies for those members with complicated ongoing social service needs that affect their ability to access and use medical services.

The following problems and/or diagnoses are examples of appropriate referrals to the SNCMU:

• Adults with Complex Medical Needs
• Cancer/Chemotherapy
• Children with Special Healthcare Needs (i.e., Cerebral Palsy)
• HIV/AIDS
• Medicare /Medicaid Dual Eligibles
• Mental Health or Substance Abuse Issues
• Mental Retardation/Developmental Disabilities
• Social Issues (homelessness, domestic violence, and substitute care)

Gateway allows for a standing referral to a specialist for sixty (60) days in certain pre-authorized situations.  The specialist must be an existing Gateway practitioner, must be agreeable to following Gateway's requirements for acting as a primary care practitioner, and must receive prior authorization by Gateway's Medical Director.  Practitioners interested in obtaining more information regarding this process should contact Provider Servicing at 1-800-392-1145.

StatusOne is Gateway's high-risk Case Management Program.  Gateway engaged a company, StatusOne Health Systems, to assist with the development of this Program.  The goal of the Program is to identify and intervene with members who will predictably become clinically unstable.  The exciting and unique aspect of StatusOne is the ability to focus case management efforts on those members who will require intensive services in the near future.  By optimizing medical care, actively engaging the patient in his own care plan, and addressing a variety of psychosocial issues, this approach to high-risk case management raises selected patients' functional status and improves their quality of life.

Gateway members enrolled in this Program will be contacted by a Nurse Care Manager.  The Nurse Care Manager will assist the member with issues such as access to care, coordination of care and reminders regarding medication and treatment compliance.  The Nurse Care Manager may on occasion contact the treating practitioner.

StatusOne is focused on proactively managing those patients with the most challenging and deteriorating clinical and psychosocial situations but with the greatest opportunity for intervention.