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Population Health Management

Cook Children's Health Plan offers Population Health Management programs to meet the needs of every Member. Members are identified through continuous case finding methods, including but not limited to:

  • State enrollment files
  • Medical management program referral (i.e., utilization review)
  • Discharge planner referral
  • Member or caregiver referral
  • Practitioner referral
  • Health needs assessments and health appraisals
  • Claims data (medical, behavioral and pharmacy)

As a Member's needs evolve over time, they may transition to a higher level of intervention in a program or to another Population Health Management program (i.e., complex case management) that offers more intensive interventions to address the Member's needs.

Upon identification of a Member for enrollment in a Population Health Management program, program staff inform the Member by interactive contact on how they became eligible for the program/service, how to use program services and how to opt-out. Interactive contact with the Member occurs through one of the following methods:

  • Telephone
  • In-person contact
  • Online contact
    • Interactive web-based module
    • Secure email
    • Video conference

Contact Information for Referrals

To refer a Member who may qualify for a Population Health Management program or speak to program staff, call 800-964-2247, Monday through Friday from 8:00 am to 5:00 pm. Confidential voicemail is available 24 hours a day.

Health Promotion

To help our Members achieve optimal health and improve health related behaviors and quality of life, we offer comprehensive care management programs that meet the needs of all Members of our health plan. Educational materials are available to our Members in multiple formats. Cook Children's Health Care System offers community courses for the parents of our child Members as well as their family members.

Regularly scheduled classes include cardiopulmonary resuscitation, asthma management and classes for parents of children with special needs. The Matustik Family Health Library, a family health library, is an excellent resource for our Members and their families. Librarians are available to assist with research.

For our adult Members (18 years and older), we provide a web-based wellness platform which includes interactive self-management tools that provide information on the following topics:

  • Healthy weight (BMI) maintenance
  • Smoking and tobacco use cessation
  • Encouraging physical activity
  • Healthy eating
  • Managing stress
  • Avoiding at-risk drinking
  • Identifying depressive symptoms

Case Management/Complex Case Management

Our case management programs offer a continuum of services. We enroll our Members with the highest health complexity in our Complex Case Management Program which provides the most intensive interventions. These programs reduce barriers to Members' access to care and treatment plan adherence through assessments to identify their unmet needs and assisting them in getting needed services. Assistance may include care coordination, providing disease/condition specific self-management education, assisting with accessing community resources or other services to address their unmet needs. Member participation in case management programs are voluntary. Program staff must obtain Member consent prior to enrollment.

Program Scope

  • Member identification for program enrollment
  • Initial comprehensive needs assessment and ongoing assessment
  • Person-centered, problem-based comprehensive care plan development, including measurable, prioritized goals and interventions
  • Care coordination with the Member's health care team
  • Monitoring of the effectiveness of the care plan through ongoing communication with a Member and their Providers
  • Satisfaction and quality of life measurement
  • Program evaluation using quantitative and qualitative data on a least an annual basis

Comprehensive Case Management Assessment

A Member who is eligible for case management services is assigned a personal case manager, either a licensed nurse or social worker. The case manager contacts the Member to conduct a comprehensive needs assessment, including but not limited to:

  • Medical condition
  • Cognitive status
  • Functional status
  • Social determinants of health (SDOH)
  • Caregiver support and health
  • Mental health conditions and substance use disorders
  • Current services
  • Unmet service needs
  • Member strengths and goals
  • Depression screening
  • Quality of life

The case manager obtains information from other sources, including the Member's Primary Care Provider and other members of their healthcare team, to develop an individualized, comprehensive care plan.

Members with Special Health Care Needs (MSHCN) and Service Management

Members with Special Health Care Needs means a Member who:

  1. Has a serious ongoing illness, a Chronic or Complex Condition, or a Disability that has lasted or anticipated to last for a significant period of time, and
  2. Requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel of Members with Special Health Care Needs are:
  • Members diagnosed with asthma, diabetes, congestive heart failure, sickle cell disease, chronic renal failure, HIV/AIDS, Neuromuscular degenerative diseases (e.g., Multiple sclerosis, muscular dystrophy) and cancer.
  • Members receiving ongoing therapy services, including physical therapy, occupational therapy and speech therapy for longer than six months.
  • Member receiving long-term support services through Personal Care Services, Private Duty Nursing, Community first Choice or Prescribed Pediatric Extended Care Center
  • Pregnant women who have a high risk pregnancy including:
  • Age 16 and younger, or age 35 and older
    • Diagnosed with preeclampsia, high blood pressure or diabetes
    • Diagnosed with mental health or substance use disorders
    • Previous history of pre-term birth
    • Members with mental illness and substance use disorder
    • Members with behavioral health issues, including substance use disorder or serious emotional disturbance or Serious and Persistent Mental Illness (SPMI) that may affect physical health or treatment plan adherence
    • Members with high-cost catastrophic cases or high service utilization (e.g., high volume of emergency department visits or inpatient admissions)
    • STAR Kids Members

Members also may request to be assessed to determine if they meet the criteria for Members with Special Health Care Needs. For Members identified as Members with Special Health Care Needs, we provide service management, including the development of a service plan, to ensure they receive covered services as well as other support services to meet their needs. Members with Special Health Care Needs have access to treatment by a multidisciplinary team when needed. Members with higher health complexity receive case management services that includes a comprehensive care plan to address their more complex needs.

Participation in service management is voluntary, and a Member may opt-out at any time. A Member must consent to receiving service management prior to enrollment in the program. A Member who consents to service management is assigned a personal service manager to assist them.

Disease Management

Disease Management services are designed to assist physicians and other health care providers in managing members with chronic conditions. Disease Management services utilize a member-centric, holistic approach. We tailor our Disease Management interventions based on a Member's risk factors, including social determinants of health impacting a Member's ability to access care or adhere to their treatment plan.

Currently we offer Disease Management programs for our Members with asthma and diabetes. Our Disease Management program model includes:

  • Proactive identification of Members for enrollment in a Disease Management program
  • Evidence-based national guidelines as the foundation of each program's design
  • Utilization of the Patient Activation Measure® (PAM®), a validated tool which assesses whether a Member has the knowledge, skills and confidence to manage their health and health care
  • Interventions tailored to individual Member needs
  • Self-management education tailored to the Member's activation level
  • Ongoing communication and collaboration with a Member's physician and service providers in treatment planning for a Member
  • Individual and program outcomes measurement
  • Registered Nurse Disease Management case managers and Certified Community Health Workers

Members have the right to opt-out of a Disease Management program at any time. If a Member elects to opt-out of a Disease Management program, their other benefits are not affected. Before enrolling a Member into a Disease Management case management level of intervention, the Member must consent to receiving case management services.

Baby Steps Program

Our Baby Steps is a proactive care management program for all expectant mothers and their newborns. It identifies pregnant women as early in their pregnancies as possible through the following methods:

  • Review of state enrollment files
  • New Member initial health needs screenings
  • Medical management program referral (e.g., utilization review)
  • Discharge planner referral
  • Member or caregiver referral
  • Practitioner referral

Once Members are identified, we initiate telephonic outreach within 5 business days to assess obstetrical (OB) risk and ensure the Member's enrollment in the appropriate intervention level of the Baby Steps program. All Members enrolled in the Baby Steps program receive written information about Baby Steps program services, how to use the services, a copy of the Baby Basics Book (available in English and Spanish) from the What to Expect Foundation, information about Text4Baby (free text messages on their cell phones through their pregnancy and the baby's first year of life), and Helpful Resources for Women Resource List.

Experienced nurse case managers enroll Members with the highest risk in case management with Members consent. Case managers work with Members and their OB providers to develop a care plan to ensure they have access to necessary services. Our high risk OB case management program offers:

  • Individualized, one-on-one case management support
  • Care coordination support
  • Educational materials and information on community resources
  • Incentives to keep prenatal and postpartum checkups and well child visits after the baby is born
  • Depression screening (Edinburgh Postnatal Depression Scale) and referral to Beacon Health Options, our behavioral health organization

If you have questions please call Provider Services at 1-888-243-3312 Monday-Friday from 8 a.m. to 5 p.m. or Contact us here