Chapter 9: Health Promotion and Care Management

In this chapter you will find quality improvement programs available to help members with identified conditions and diseases.

EmblemHealth has health and wellness programs, tools, and resources to help members enhance their quality of life. For tips and information on preventive care, wellness benefits, chronic disease management, self-care, and more to share with our members, visit emblemhealth.com/live-well. 

EmblemHealth promotes the following quality improvement initiatives through newsletters and other educational materials available to members and providers:

Women's Health

• Breast cancer screening
• Cervical cancer screening
• Chlamydia screening
• Osteoporosis and musculoskeletal health
• Timely prenatal and postpartum care

Adult Health

• Annual well-care visits
• Cardiac care
• Cholesterol management
• Colorectal cancer screening
• Depression screening
• High blood pressure management
• Influenza and pneumonia vaccinations
• Stress management
• Weight management
• Appropriate use of antibiotics
• Respiratory management (COPD and asthma)
• Medication management and safety
• Tobacco, alcohol and substance abuse counseling

Childhood and Adolescent Health

• Annual well-care visits
• Vaccinations
• Lead screening
• Dental screening
• Depression screening
• Developmental screening
• Hearing screening
• Adolescent immunizations
• Adolescent screening and counseling for:
  • Exercise
  • Nutrition
  • BMI and weight management
  • Sexual activity
  • Tobacco and substance abuse

Activities and Goals

EmblemHealth has a Population Health Management model that identifies prospective high-risk members who require help to meet their care needs. EmblemHealth's care management goal is to address our members’ needs in the following focus areas:

• Keeping members healthy.
• Managing members with emerging risk.
• Patient safety or outcomes across settings.
• Managing multiple chronic illnesses.

Using sophisticated predictive modeling tools, we can identify members with evolving risks and provide them with care as early as possible. We can also identify members who would most benefit from field-based care management. Our programs and initiatives are designed to complement the traditional medical care our members receive.

Activities include, but are not limited to:

• Providing care management services that include:
  • disease assessments
  • health education
  • depression screening
  • case management
• Screening for social determinants of health (SDOH) that can act as barriers to receiving care, such as access to suitable food, financial, or transportation issues. Directing members to appropriate resources.
• Collaborating with community-based organizations and hospitals to improve transitions of care from one setting to another and between different levels of care.
• Coordinating care between primary care practitioners and specialists, as well as behavioral health and medical practitioners.
• Supplying treating practitioners with member information regarding progress, educational materials, and other services.
• Scheduling outbound calls.
• Virtual/Face-to-face interactions with care management staff.
• Ongoing education, as appropriate to each program.

Program goals include:

• Improved adherence with physician instructions.
• Appreciable member continuum of care coordinated across potential settings, providers, and levels of care.
• Increased patient knowledge of their condition.
• Symptom improvement and/or stabilization.
• Reduction in inappropriate utilization.
• Positive behavioral health changes.

Members are identified for these programs through our analysis of:

• Health risk surveys.
• Claims data.
• Self-referrals.
• Caregivers.
• Discharge planners.
• Referrals from practitioners.

Practitioners may refer members to our care management programs, or the member may contact us directly at 800-447-0768 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday to Friday. 

Enrollment is voluntary and, if applicable, allows members to receive:

• Educational tools to assist with:
  • understanding their diseases
  • symptom management
  • diet and nutrition needs
  • treatment options
  • preparing for doctor visits
• An opportunity to work one on one with a nurse, social worker, or behavioral health care manager by telephone or face-to-face interaction.
• Access to community-based support services.
• Access to additional care through our other care management programs.

Program Components

The care management programs support practitioner care plans by using evidence-based clinical practice guidelines (CPGs) to highlight ways to prevent complications and flare-ups of chronic conditions. Clinical practice guidelines are updated regularly in Clinical Corner on emblemhealth.com. Check monthly for updates.

Key components include:

• Matching members with disease-specific programs that meet their individual needs.
• Prompting practitioners and members to follow evidence-based clinical practice guidelines in treating chronic illness.
• Coordinating care among:
  • medical and behavioral health practitioners
  • support services providers
  • the health plan
  • the member
  • caregivers
• Educating and empowering members to make lifestyle choices that may prevent or control their conditions (including behavioral modification and compliance/surveillance).
• Providing health coaching and monitoring centered around a care plan created by a registered nurse and/or other clinically trained or licensed health professional.
• Appropriate use of information technology including:
  • specialized software
  • data registries
  • automated decision support tools
  • tickler systems for materials and/or calls
• · Measuring progress and outcomes of care for quality improvement, reporting, and performance-based payment.

Note: For members with multiple chronic illnesses, or with severe or end-stage illness, patient preferences and needs should take precedence over guidelines-based care. Such members require highly individualized care plans and may not be suited for participation in some care management programs.

Tobacco-Free Quit-Smoking Program

EmblemHealth has partnered with the New York State Smokers Quitline (NYSSQL) to provide comprehensive smoking cessation services. NYSSQL is a state program based at the Roswell Park Cancer Institute in Buffalo, New York. The program is available at no cost to all New York State residents.

Services available through the NYSSQL include:

• Help developing a quit plan by phone from trained quit-smoking experts.
• Recorded phone messages and tips available 24 hours a day, seven days a week.
• Receipt of educational guides and materials by mail.
• A two-week supply of nicotine replacement therapy (nicotine patch or gum) for those who qualify.
• Access to information and services through the New York State Quitline website.

The Tobacco-Free Quit-Smoking Program is also implemented by Roswell Park. In addition to the NYSSQL benefits for New York residents, eligible EmblemHealth members ages 18 and older enrolled in the Tobacco-Free Quit-Smoking Program receive the following services:

• Full coverage for smoking cessation medication (nicotine patch, gum, lozenge, bupropion [generic Zyban®], and Chantix®) for members with EmblemHealth pharmacy benefit coverage enrolled in the Tobacco-Free Quit-Smoking Program within one year of program enrollment. Medicare members are responsible for a copay for the smoking-cessation prescription products.
• Unlimited one-on-one support and help developing a quit plan by phone from trained quit-coach experts.

Practitioners are encouraged to refer members directly to the New York State Smokers Quitline at 866-NY-QUITS (866-697-8487), or 311 in New York City. Referral forms can be found online at nysmokefree.com. For out-of-state members, referrals can be made directly to the program by calling 877-500-2393.

Studies show that a follow-up visit or phone call within one week of the patient's quit date can double the effectiveness of any intervention. EmblemHealth provides reimbursement for smoking-cessation counseling based on current Centers for Medicare & Medicaid Services guidelines. We reimburse for CPT codes 99406 and 99407.

Healthy Living Program

EmblemHealth provides many tools to help members manage their weight. Visit the Provider Weight Management Resources section of emblemhealth.com for information about:

• Body mass index (BMI)
• Clinical practice guidelines
• Screening recommendations
• Coding and tools

Centers of Excellence (COE) Program

Select EmblemHealth members with serious injuries or illnesses related to cancer or orthopedics and musculoskeletal conditions have access to our industry-leading hospital partners, Memorial Sloan Kettering Cancer Center and Hospital for Special Surgery. EmblemHealth’s care management programs work collaboratively with the COE care teams to provide care coordination to address member needs. 

EmblemHealth chose these Centers of Excellence partners after a competitive evaluation process because they are as committed as we are to meet the needs of our members. These top hospitals and doctors are nationally recognized for their high-quality, patient-focused care and best-in-class research, training, and technology standards. They have many convenient locations throughout Manhattan, Long Island, Westchester, and New Jersey.

Managing Entity Care Management Programs

SOMOS and HealthCare Partners (HCP) offer care management programs for EmblemHealth members who receive treatment under their care. For questions or more information about their care management programs, call: 

• HCP at 800-877-7587 (TTY: 711) available 24/7.
• SOMOS at 855-225-3211.

The Care for the Family Caregiver initiative provides information, resources, and support to promote awareness and understanding of the key role of the family caregiver within the health care system. Through its programs, community outreach, and partnerships, Care for the Family Caregiver provides support and encouragement to family caregivers. For details, visit Care for the Family Caregiver.

EmblemHealth also hosts and sponsors the NYC Family Caregiver Coalition.