Preventive Health, Disease and Case Management

The Gateway Health Plan Medicare Assured^® HMO Preventive Health Program focuses on the importance of health screening and early detection of diseases. Key interventions of the program include:

Reminders for preventive health screenings
Telephonic outreach to assist members in scheduling mammograms when indicated
Physician notification of members overdue for mammograms and/or pap smears
Member newsletters with articles focusing on the importance of Preventive Health
Health screening information on the Gateway Health Plan Medicare Assured^® HMO website

For more information, please call 1-800-685-5212 and press option 4 to speak with an Outreach Representative.

Disease Management Programs

MOM Matters^® Program

The MOM (Maternity Outreach and Management) Matters^® Prenatal Program offers maternity care coordination to improve the frequency of prenatal and postpartum care to reduce the incidence of low birth weight, pre-term deliveries and NICU admissions. This is a population-based program directed toward improving outcomes for all pregnant members. Specific interventions are designed to identify and prospectively intervene with members at high risk for adverse pregnancy outcomes.

All identified pregnant Gateway members are automatically enrolled once we identify them with one of the high risk maternity conditions via the OB Needs Assessment Form. Maternity Care Managers telephonically contact these members. Members are able to opt-out if they choose.

The program will provide the following member benefits and support:

Patient education
Prenatal educational packet mailed to all identified pregnant members
Home care and DME needs are coordinated through the Gateway Nurse Care Manager
Information on smoking with referral to the state Quitline
Member newsletter with related maternity articles
MOM Matters^® information via Gateway Health Plan^® website
Prenatal Reward Program Brochure

Provider benefits:

Support from our nurses and other health care staff to ensure that your patients understand how to best manage their condition and self evaluate their health status.
Health education information mailed to all identified pregnant members
Telephonic case management and coordination of care for high risk patients
An enrollment notification form is faxed to the OB provider upon member eligibility for the program
• A bonus payment to PCPs and OB/GYNs for rendering initial prenatal visit within the first trimester.

Membership in the MOM Matters^® Prenatal Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call.

For more information or to refer a patient to the MOM Matter^® Program call 1-800-685-5212, and press option 2.

Asthma Program

"AIR” (Asthma Intervention gets Results) Gateway^® is an asthma management program emphasizing patient education, self-management, practitioner education and support to increase appropriate medication use and reduce acute care asthma utilization.

Gateway members with asthma between the ages of 2 and 56 years of age are enrolled in the program. Asthma Care Managers telephonically contact members identified as being at high risk for complications secondary to their asthma. Members are automatically enrolled once identified with asthma. They are able to opt-out if they choose.

Referral to the AIR Gateway^® Program can be made by telephone or by completion of the Asthma/Cardiac Fax Referral Form which is located in the Forms and Reference Material Section of this manual.

The program will provide the following member benefits and support:

Patient education and self-management tools
Asthma education provided
Asthma action plan
Information on smoking with referral to the state Quitline
Member newsletter with asthma related articles
"AIR" Gateway^® information via the Gateway Health Plan^® website

Provider benefits and support:

Support from our care managers and other health care staff to ensure that your patients understand how to best manage their condition and self evaluate their health status
An enrollment notification form is faxed to the PCP upon member eligibility for case management
Patient education and assistance with co-existing conditions, smoking cessation and medication compliance supports optimal self-management

Membership in the Asthma Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call.

For more information or to refer a patient to the AIR Gateway^® Asthma Program call 1-800-685-5212, and press option 3.

Diabetes Program

The Healthy Returns Diabetes Program emphasizes education and personal responsibility for diabetic control to reduce the need for hospitalizations, ER visits and prevention of diabetic complications. Pharmacists, nurses and dieticians are available by phone for members and physicians.

All adult and pediatric Gateway members with Type 1 or Type 2 diabetes are eligible for this program. Members are automatically enrolled once we identify them with diabetes. They are able to opt-out if they choose.

The program will provide the following member benefits and support:

Support from our nurses and other health care staff to ensure that your patients understand how to best manage their condition and self evaluate their health status
Members with diabetes receive educational materials and may call to join the care management program
Targeted reminders to patients who are due for screenings
24/7 phone access to a nurse
Home care and DME needs are coordinated via collaboration with Gateway’s Utilization Management Department.
Member newsletter with diabetes related articles
Diabetic information via Gateway Health Plan^® website

Provider benefits and support:

Diabetic educational materials are mailed to your patients
Medication profile reports are mailed to the primary care practitioner to assist with optimal medication management
An enrollment notification form is forwarded to the primary care practitioner upon member eligibility for case management
Patient education with co-existing conditions, smoking cessation and glucometer use reduces likelihood of hospital admissions

For more information or to refer a patient to the Healthy Returns Diabetes Program, call 1-866-366-9415.

Help Your Heart Cardiac Program

The Help Your Heart Cardiac Program provides patient education and self-empowerment for medication adherence to reduce the need for hospitalizations and ER visits and to delay the onset of cardiac complications.

Gateway members, age 21 or older, with a diagnosis of CHF, Ml, and CAD with a PTCA or CABG are eligible for the program. Members are automatically enrolled once we identify them with one of these cardiac conditions. They are able to opt-out if they choose.

Referral to the Help Your Heart Program can be made by telephone or by completion of the Asthma/Cardiac Fax Referral Form which is located in the Forms and Reference Material Section of this manual.

The program will provide the following member benefits and support:

Patient education and self-management tools
Cardiac information
High-risk cardiac patients with inpatient admissions receive telephonic case management
Information on smoking with referral to the state Quitline
Member newsletter with cardiac related articles
Help Your Heart information via Gateway Health Plan^® website
Home care and DME needs are coordinated through the Gateway Nurse Case Manager

Provider benefits and supports:

Support from our care managers and other health care staff to ensure that your patients understand how to best manage their condition and self evaluate their health status
Cardiac specific educational materials are mailed to patients
An enrollment notification form is faxed to the primary care practitioner upon member eligibility for care management
Patient education for co-existing conditions, smoking cessation, medication compliance and weight supports optimal self-management

Membership in the Cardiac Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call.

For more information or to refer a patient to the Help Your Heart Program, call 1-800-685-5212 for Pennsylvania providers, and press option 3.

Care Management

General Information

The goal of the Care Management Department is to intervene in medically or socially complex cases that may benefit from increased coordination of services to optimize health and prevent disease. The Care Management Department is staffed by individuals with medical or social work backgrounds in the following areas: obstetrics, oncology, medical/surgical, HIV/AIDS, substance abuse, mental health, and physical rehabilitation.

A Care Manager is available at 1-800-685-5212, 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, please refer to the Quick Reference section in this manual for the Member Services phone number.

Care management is a creative and collaborative process involving skills such as assessment, planning, coordination and advocacy. Care 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 care management process includes:

Assessment
Planning
Intervention
Quality Monitoring
Evaluation/Reassessment

The responsibilities of the case management include:

Liaison with various healthcare practitioners, community social service agencies, advocacy groups and other agencies that the Medicare Assured^® population may interface with;
Case management of members with serious and complex needs;
Coordination of services between primary care, specialty, ancillary, and behavioral health practitioners within and outside the network;
Facilitation of members’ access to city, county and state and social agencies for those members with complicated ongoing social service needs that affect their ability to access and use medical services.

Criteria for Referrals to the Case Management Department

The following problems and/or diagnoses are examples of appropriate referrals to the Case Management Department:

Adults with Serious and Complex Medical Needs
Children with Special Healthcare Needs
Mental Health or Substance Abuse Issues
Social Issues (social isolation, hunger, housing, domestic violence)

Complex Care Management:

Gateway provides a Complex Care Management program for eligible members. Gateway’s Care Managers help to identify and then provide support, direction and intervention to help members manage the following complex diseases:

Chronic Obstructive Pulmonary Disease (COPD) on oxygen
Cancers with metastasis
Pulmonary hypertension
Stage IV heart failure
Symptomatic HIV/AIDS
New traumatic brain injury with significant cognitive deficits
Spinal cord injury with paralysis

The practitioner’s role in Gateway’s Complex Care Management program is extremely important. Practitioners who have identified a member who they think would benefit from this program should contact the Care Management Department to speak with a Care Manager at 1-800-685-5212, option 1.

Gateway will review the request for enrollment and make the final decision for inclusion in the program.